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38 185 neuraxial drug administration errors from 40 countries – practical issues and human factors
  1. S Patel1,
  2. R Paskaleva2 and
  3. D Agrawal3
  1. 1Tawam Hospital, Al Ain, United Arab Emirates
  2. 2Airedale NHS Foundation Trust, Airedale, UK
  3. 3North Manchester General Hospital, Manchester, UK


Background and Aims We reviewed country-wise reporting of neuraxial route drug administration errors.

Methods Medline and Google scholar database were searched for neuraxial drug errors through February 2021 using terms including ‘epidural drug error’. The search was also done using ‘intrathecal’ and ‘neuraxial’ words in place of epidural. Local anaesthetic (LA) and opioids errors were excluded. Medication errors were grouped, countries reporting recorded and industry issues and human factors were identified.

Results 185 neuraxial drug administration errors were reported from 40 countries involving different group of drugs (table 1). 47.5% errors were reported from 5 countries: USA (33), UK (15), India (17), Korea (12) and Iran (11). Other 5 countries reported ≥ 5 to 10 errors: Benin (8 in a single report), Germany (7), Turkey (7), Netherlands (6), Australia (5).

Off 34 tranexamic acid errors (from 13 countries), 7 occurred in India. 8 European union countries reported 15 (out of 28) potassium chloride errors. Neuromuscular blocking drugs related events were widespread (21 errors from 13 countries). Cardiovascular drug incidents (34) were mainly reported from the USA (9) and UK (6).

Table 2 summarises some issues related to pharmaceutical industry and clinical practice.

Recurrent human factors identified are summarised in table 3.

Abstract 38 Table 1

Neuraxial errors reporting countries.Number represents number of patients

Abstract 38 Table 2

Some pharmaceutical and practice issues among countries reporting errors

Abstract 38 Table 3

Human factors ( identified and their corrections

Conclusions Manufacturing of look-alike of LA, fentanyl, normal saline and several high-risk ampoules (e.g. tranexamic acid, KCl, digoxin, NMBDs) or vials is one major uniform factor. Robust organisational, supervisory and local clinical practices are needed to correct latent human failures.Universal applications of four recommendations1–4 (table 3) would prevent drug administration errors during neuraxial anaesthesia or analgesia.

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