Inadvertent administration of non-epidural medications into the epidural space has the potential for serious morbidity and mortality. The aim of this study was to collate reported incidents of this type, describe the potential mechanisms of occurrence and identify possible solutions. We searched medical databases and reviewed reference lists of papers retrieved, covering a period of 35 years, regarding this type of medication incident. The 31 reports of 37 cases found is likely to represent a gross underestimation of the actual number of incidents that occur. “Syringe swap”, “ampoule error”, and epidural/intravenous line confusion were the main sources of error in 36/37 cases (97%). Given that no effective treatment for such errors has been identified, prevention should be the main defence strategy. Despite all the precautions that are currently undertaken, accidents will inevitably occur. We have identified areas for system-wide change that may prevent these types of incidents from occurring in future.
BraunR., BucheI., JahnU.R., ThieleH.H., Van AkenH.Accidental application of amoxicillin/clavulinic acid via an epidural catheter.Anasthesiologie und Intensivmedizin2000; 41: 680–681.
TesslerM.J., WhiteI., Naugler-ColvilleM.A., BiehlD.R.Inadvertent epidural administration of potassium chloride. A case report.Can J Anaesth1988; 35: 631–633.
18.
LiuK., ChiaY.Y.Inadvertent epidural injection of potassium chloride. Report of two cases.Acta Anaesthesiol Scand1995; 39: 1134–1137.
19.
VercauterenM., SaldienV.Epidural injection of potassium hydrochloride.Acta Anaesthesiol Scand1996; 40: 505.
20.
PeadutoV.A., MezzettiD., GoriF.A clinical diagnosis of inadvertent epidural administration of potassium chloride.Eur J Anaesthesiol1999; 16: 410–412.
21.
Bermejo-AlvarezM.A., CosioF., HeviaA., Iglesias-FernandezC.Accidental epidural administration of potassium chloride.(Spanish) Revista Espanola de Anestesiologia y Reanimacion2000; 47: 323–324.
22.
do NascimentoP.Jr, ModoloN.S.P., MelettiJ.F.A.Braz JRC. Sympathetic hyperactivity, respiratory failure, pruritus and anesthesia after unintentional epidural injection of potassium chloride: case report.Reg Anesth Pain Med1998; 23: 219–222.
23.
PaganiI., CarnevaleL., BonezziC., PreseglioI.Description of a clinical case of inadvertent peridural injection of 15% potassium chloride.(Italian) Minerva Anestesiol1984; 50: 407–410.
24.
LinD., BeckerK., ShapiroH.M.Neurologic changes following epidural injection of potassium chloride and diazepam: a case report with laboratory correlations.Anesthesiology1986; 65: 210–212.
25.
LitzR.J., KreineckerI., HublerM., AlbrechtD.M.Inadvertent infusion of a high dose of potassium chloride via a thoracic epidural catheter.Eur J Anaesthesiol2001; 18: 697–699.
26.
KulkaP.J., StratesteffenI., GrunewaldR.G., WiebalckA.Inadvertent potassium infusion into an epidural catheter.Anaesthesist1999; 48: 896–899.
GentiliM.E., SamiiK.Accidental epidural injection of hyper-tonic sodium chloride solution.(French) Ann Fr Anesth Reanim1991; 10: 401–403.
29.
PatelP.C., SharifA.M., FarnandoP.U.Accidental infusion of total parenteral nutrition solution through an epidural catheter.Anaesthesia1984; 39: 383–384.
McGuinessJ.P., CanteesK.K.Epidural injection of a phenol-containing ranitidine preparation.Anesthesiology1990; 73: 553–555.
32.
MappesA., SchaerH.M.Accidental injection of ether into the epidural space.Anaesthesia1991; 46: 124–125.
33.
KasabaT., UeharaK., KatsukiH., OnoY., TakasakiM.Analysis of inadvertent epidural injection of drugs.(Japanese) Masui2000; 49: 1391–1394.
34.
CheneyF.W., DominoK.B., CaplanR.A., PosnerK.L.Nerve injury associated with anesthesia. A closed claims analysis.Anesthesiology1999; 90: 1062–1069.
35.
PengP.W., SmedstadK.G.Litigation in Canada against anesthesiologists practicing regional anesthesia. A review of closed claims.Can J Anaesth2000; 47: 105–112.
36.
FennP., DiaconS., GrayA., HodgesR., RickmanN.Current cost of medical negligence in NHS hospitals: analysis of claims database.Br Med J2000; 320: 1567–1571.
37.
CurrieM., MackayP., MorganC.The “wrong drug” problem in anaesthesia: an analysis of 2000 incident reports.Anaesth Intensive Care1993; 21: 596–601.
38.
Bickford SmithP.J.Not again! Designing safer medical devices requires financial and political support.Br Med J2001; 322: 548.
39.
ReinertsenJ.L.Let's talk about error. Leaders should take responsibility for mistakes.Br Med J2000; 320: 730.
40.
RuncimanW.B., SellenA., WebbR.K.Errors, incidents and accidents in anaesthetic practice.Anaesth Intensive Care1993; 21: 506–519.
41.
MerryA.F., WebsterC.S., MathewD.J.A new, safety-oriented, integrated drug administration and automated anesthesia record system.Anesth Analg2001; 93: 385–390.
42.
MerryA.F., WebsterC.S.Labelling and drug administration error.Anaesthesia,1996; 51: 987–988.
43.
LawsD.The time has come for non-interchangeability of spinal and epidural equipment with intravascular access ports.Br J Anaesth2001; 86: 903.
44.
LaniganC.J.Safer epidural and spinal connectors.Anaesthesia2002; 57: 567–571.
45.
BerwickD.M.Not again!Br Med J2001; 322: 247–248.
46.
CynaA.M., SimmonsS.W., OsbornK., AndrewM.Fatal epidural infusion—call for a system wide change.Anaesth Intensive Care2002; 30: 99–100.
47.
DyerC.Doctors suspended after injecting wrong drug into spine.Br Med J2001; 322: 257.
48.
HarcourtV.Coronial warning after fatal epidural infusion.Australian and New Zealand College of Anaesthetists Bulletin2001; 10: 5–6.
49.
WebsterC.S., MerryA.F., LarssonL., McGrathK.A., WellerJ.The frequency and nature of drug administration error during anaesthesia.Anaesth Intensive Care2001; 29: 494–500.
50.
SapstedD.Patient died after being injected with wrong fluid, Electronic Telegraph, 2 May 2001; Issue 2168: Available from: URL: http://www.telegraph.co.uk
