Neuraxial and Peripheral Misconnection Events Leading to Wrong-route Medication Errors: A Comprehensive Literature Review

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.

Extension of patient safety initiatives to perioperative care

“…To reduce them, medicines should be stored in their pharmacological class grouping rather than alphabetical order; preparation of injectable medicines should take place on a clean uncluttered standardized surface; and syringes need to be clearly labelled using ISO 26825 standards for colored labels, using prefilled syringes when available [37]. Wrong route administration needs to be reduced in the perioperative period by introducing specific connectors for enteral and neuraxial (ISO 80369) administration differentiated from the Luer-lock intravenous lines [38 ▪ ]. Moreover, medication safety issues are a major problem along the perioperative period before and after surgery.…”