Table 2

Individual drugs and other substances noted in a single case report involving neuraxial and peripheral misconnections, leading to wrong-route administration events

Drug type, name	Intended route of administration	Actual route of administration	Incident severity*
Antibiotics
Cefotiam	Intravenous	IT	Moderate
Clindamycin	Intravenous	EPI	Low
Piperacillin-tazobactam	Intravenous	EPI	Moderate
Rifampicin	Intravenous	IT	Low
Chemotherapy
Bleomycin	Intravenous	IT	Moderate
Doxorubicin	Intravenous	IT	Severe
Farmorubicin	Intravenous	IT	Death
PEG-asparaginase	Intramuscular	IT	Low
Contrast agents
Diatrizoate meglumine	Intravenous	IT	Moderate
Iothalamate meglumine	Intravenous	IT	Moderate
Ioxaglate sodium	Intravenous	IT	Moderate
Ioxitalamate	Intravenous	IT	Moderate
Muscle relaxants
Cisatracurium	Intravenous	EPI	Moderate
Pancuronium	Intravenous	EPI	Low
Opioids
Hydromorphone	Intravenous	EPI	Moderate
Remifentanil	Intravenous	EPI	Low
Tramadol	Intravenous	IT	Death
Other
Insulin	Intravenous	EPI	Moderate
Labetalol—beta blocker	Intravenous	IT	Low
Mercurochrome	TOP	IT	Severe
Neostigmine + atropine	Intravenous	EPI	Moderate
Parenteral nutrition	Intravenous	EPI	Moderate
Phenylephrine	Intravenous	EPI	Moderate
Phenytoin	Intravenous	ED	Moderate
Physostigmine (cholinesterase inhibitor)	Intravenous	IT	Low
Sodium chloride, ketorolac, esomeprazole, cefotaxime	Intravenous	EPI	Low

*Incident severity, as defined by the National Reporting and Learning System,23 is as follows: (Low) Any unexpected or unintended incident that required extra observation or minor treatment and caused minimal harm to ≥1 person; (Moderate) Any unexpected or unintended incident that resulted in further treatment, possible surgical intervention, or canceling of treatment, or transfer to another area, and which caused short-term harm to ≥1 person; (Severe) Any unexpected or unintended incident that caused permanent or long-term harm to ≥1 person; (Death) Any unexpected or unintended event that caused the death of ≥1 person.
ED, extraventricular drain; EPI, epidural; IT, intrathecal; PEG, polyethylene glycosylated; TOP, topical.