Neuraxial Medication Administration Errors During Anaesthesia and Perioperative Management, Consequences, Contributing Human and Systemic Factors and Their Prevention: A Systematic Review.
Neuraxial medication administration errors can lead to serious harm, including irreversible paralysis and death, primarily due to antiseptic administration mistakes.
Where it sits
this study against the rest of the carbetocin corpusSummary and findings
This systematic review investigated neuraxial administration errors, their contributing factors, and clinical outcomes using a novel harm scale. The review included 50 reports involving 54 patients, with a focus on epidural administration. Key findings included serious adverse events associated with antiseptic administration.
Abstract
Introduction This systematic review aimed to investigate neuraxial administration errors, examine their contributing factors, and evaluate clinical outcomes using a novel harm scale. Methods The author searched PubMed, Web of Science, Scopus, EBSCOhost, and Google Scholar for reports from 1981 to 2025 in any language. Exclusions were reviews, overdose incidents, and non-neuraxial administrations. Harm was classified using a novel five-level scale, and contributing factors were identified using the Human and Systemic Factors Analysis Classification System (HFACS). Results The search revealed 50 reports (54 patients), mainly involving the epidural route (38 vs 16 intrathecal), non-obstetric patients (35 vs 17 obstetric), and female gender (73%). Medications were grouped into nine divisions: IV fluids/total parenteral nutrition/insulin, anticholinergics, antiseptics, antiemetics, anticoagulants, non-steroidal anti-inflammatory drugs, opioids, Syntocinon, and others. Atropine (6 patients) was the most common, followed by remifentanil (4), Syntocinon (4), chlorhexidine (3), and water (3). Level 4 events (irreversible paraplegia or quadriplegia, 4 patients) and level 5 events (death, 4 patients) were mostly due to accidental antiseptic bolus administration. Inadvertent neuraxial drug administration occurred at different locations and during various stages of clinical care. The Human Factors Analysis Classification System (HFACS) identified unsafe acts related to skill-based errors and misidentification of routinely used objects. Additional deficiencies included organisational processes, resources, supervision, and task execution for neuraxial anaesthesia or analgesia. Conclusions Level 4 and 5 harm was mainly associated with the administration of antiseptic solutions. The HFACS framework-based analysis suggested multiple modifiable institutional and individual deficiencies. Multidisciplinary improvements of organisational safety procedures, relevant preconditions, and neuraxial clinical practices may help prevent these serious incidents.
Background
This paper addresses the clinical issue of medication administration errors during neuraxial procedures, which can lead to severe patient harm. Prior literature has documented various errors and their consequences, but a systematic review focusing on contributing factors and outcomes is necessary to enhance understanding and prevention strategies. The study's findings are crucial for improving safety protocols in anesthetic practices.
Methods
The authors conducted a systematic review by searching multiple databases for reports from 1981 to 2025. Excluded were reviews, overdose incidents, and non-neuraxial administrations. The review classified harm using a five-level scale and identified contributing factors through the Human and Systemic Factors Analysis Classification System (HFACS).
Results
The review identified 50 reports involving 54 patients, with the majority of errors occurring via the epidural route (38 patients) compared to intrathecal (16 patients). Level 4 events were reported in 4 patients, while level 5 events were also reported in 4 patients. The most common medication error involved atropine (6 patients), followed by remifentanil (4) and Syntocinon (4).
Interpretation
The findings indicate that while the statistical significance of the reported harm levels is clear, the clinical implications are severe, as they involve life-altering consequences for patients. The study highlights the importance of addressing human and systemic factors contributing to these errors. However, the reliance on a limited number of reports and the exclusion of certain incidents may limit the generalizability of the conclusions.
Key findings
- 54 patients reported across 50 studies.
- Level 4 events (irreversible paraplegia or quadriplegia) occurred in 4 patients.
- Level 5 events (death) occurred in 4 patients.
- 73% of patients were female.
- Atropine was the most common medication error, involving 6 patients.
Limitations
- small n=54 patients across 50 reports
- exclusion of overdose incidents may limit findings
- focus on specific medication errors may not capture all risks
- potential publication bias in reported cases