Alert practitioners to key strategies to reduce the risk of significant harm to patients.
The Institute for Safe Medication Practices (ISMP) recently learned about 3 cases of accidental spinal injection of tranexamic acid instead of a local anesthetic intended for regional (spinal) anesthesia.
Container mix-ups were involved in each case. In 1 case, a patient scheduled for knee surgery received tranexamic acid instead of bupivacaine. The anesthesiologist immediately realized the error, but by then, the patient had begun to experience seizures. The patient recovered. In a second case, a patient undergoing hip replacement surgery received tranexamic acid instead of a local anesthetic for spinal anesthesia. The patient survived but experienced seizures and had extreme pain due to arachnoiditis. In a third case, a patient scheduled for bilateral knee replacement also inadvertently received tranexamic acid instead of bupivacaine for spinal anesthesia. The patient experienced seizures, which necessitated placing her into an induced coma for several days.
The ISMP has previously reviewed errors with tranexamic acid and noted that in the United States, bupivacaine, ropivacaine, and tranexamic acid are packaged in vials that may have the same blue color cap.1 Although label colors and vial sizes may be different, when the vials are stored upright near each other, only the blue caps may be visible, making it more difficult to differentiate 1 drug from another. To make matters worse, these drugs are often found in areas where bar code scanning may not have been implemented or is not routinely used, such as the emergency department, labor and delivery, or perioperative areas, so mix-ups are less likely to be detected. Syringe labeling issues may also contribute to such errors. The literature has additional reports of serious patient harm because of wrong-route errors with tranexamic acid.2-5
Tranexamic acid is an antifibrinolytic that prevents the breakdown of fibrin, thus promoting clotting. It is approved for short-term use (2 to 8 days) in patients with hemophilia to reduce the risk of hemorrhage during and following tooth extraction. It is also used off-label in a variety of hemorrhagic conditions to control bleeding, including postpartum hemorrhage. Although tranexamic acid is not indicated for joint surgeries, it is often used intravenously (IV) or topically during these procedures to decrease blood loss. Tranexamic acid is also available as an oral tablet for the treatment of cyclic heavy menstrual bleeding in women.
When given via the spinal route in error, tranexamic acid is a potent neurotoxin that is harmful to patients, with a mortality rate of about 50%. Survivors often experience permanent neurological injury, paraplegia, seizures, and ventricular fibrillation.6
SAFE PRACTICE RECOMMENDATIONS
Here are some tips for dealing with tranexamic acid:
MICHAEL J. GAUNT, PHARMD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.