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Review
. 2021 Feb;46(2):176-181.
doi: 10.1136/rapm-2020-101836. Epub 2020 Nov 3.

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

Eugene R Viscusi  1 , Vincent Hugo  2 , Klaus Hoerauf  2   3 , Frederick S Southwick  4
Affiliations
Review

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

Eugene R Viscusi et al. Reg Anesth Pain Med. 2021 Feb.

Abstract

We conducted a search of the literature to identify case reports of neuraxial and peripheral nervous system misconnection events leading to wrong-route medication errors. This narrative review covers a 20-year period (1999-2019; English-language publications and abstracts) and included the published medical literature (PubMed and Embase) and public access documents. Seventy-two documents representing 133 case studies and 42 unique drugs were determined relevant. The most commonly reported event involved administering an epidural medication by an intravenous line (29.2% of events); a similar proportion of events (27.7%) involved administering an intravenous medication by an epidural line. Medication intended for intravenous administration, but delivered intrathecally, accounted for 25.4% of events. In the most serious cases, outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride. These case reports confirm that misconnection events leading to wrong-route errors can occur and may cause serious injury. This comprehensive characterization of events was conducted to better inform clinicians and policymakers, and to describe an emergent strategy designed to mitigate patient risk.

Keywords: anesthesia; drug-related side effects and adverse reactions; injections; local; nerve block; neurotoxicity syndromes; spinal.

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Conflict of interest statement

Competing interests: FSS declares no conflicts of interest. VH and KH are employees of Becton, Dickinson and Company and own stock or stock options in the company. ERV receives consulting fees from AcelRx, Concentric, Heron Therapeutics, Innacoll, Merck, Neumentum, Pfizer, Recro, Salix, and Trevena.

Figures

Figure 1
Figure 1
Neuraxial and peripheral nerve block misconnection errors identified in case reports (N=130) between 1999 and 2019. Intended route unknown for 3 of 133 cases. IV, intravenous; PNB, peripheral nerve block.
See this image and copyright information in PMC

Comment in

References

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