[Mix-up of medication in spinal anaesthetics].

BACKGROUND

Administration of the wrong medication can cause severe injury and harm to the patient; it can also have a big impact on the healthcare professionals involved.

CASE DESCRIPTION

We describe two patient cases in which the antifibrinolytic agent tranexamic acid was accidentally administered instead of the planned anaesthetic drug bupivacaine. The medication mix-up resulted in serious adverse outcomes for both patients. Both incidents were the result of a sequence of the following human errors and system failures: (1) the packaging for bupivacaine and the label for tranexamic acid were altered; (2) the spinal trolley was restocked incorrectly; and (3) the medication was not double-checked before administration.

CONCLUSION

These cases illustrate how important it is to carefully adhere to safety procedures, such as double-checking of medication. Care providers must see to it that these procedures are also complied with if circumstances change. If necessary, the safety procedures must be adapted.