​Statement on Standard Practice for Avoidance of Medication Errors in Neuraxial Anesthesia

Developed By: Committee on Quality Management and Departmental Administration
Last Amended: October 15, 2025 (Original Approval: October 20, 2010)

Medication errors related to the neuraxial (epidural or spinal) route are a significant and preventable cause of harm, with a potential for catastrophic complications. This statement provides guidance on some practices for avoiding medication errors related to inadvertent neuraxial administration.

When an anesthesia professional performs a neuraxial procedure immediately after drawing up prepackaged medications from the procedural tray, then labeling of syringes in the tray is not required. If the neuraxial procedure is not performed immediately, then labeling of syringes is advised. Careful reading of the label on the ampule or vial must be done before the drug is drawn up.

When the anesthesia professional is using medications that are not pre-packaged in the spinal or epidural kit or needs assistance from another healthcare professional for the neuraxial procedure or to access medications, labeling of syringes is advised. When using medications from outside the prepackaged kit (e.g. local anesthetics, opioids, or preservative-free saline), the following should be adhered to:

1. Careful reading of the vial or ampule before the drug is drawn up must be done. The label on the medication should be checked both by the person performing the neuraxial procedure and another licensed healthcare professional, if available. Barcode technology may be helpful, if available.
2. Syringes should be labeled in accordance with accepted standards as defined in the ASA Statement on Labeling of Pharmaceuticals for Use in Anesthesiology.

Attention should be paid to avoid the possibility of accidental neuraxial administration of medications meant to be administered intravenously. Several reports have been published about medications that were accidentally administered neuraxially (See appendix*), with mild to severe morbidity, and mortality being described. Drugs of particular importance include tranexamic acid and digoxin:

The accidental neuraxial administration of tranexamic acid has been associated with neurological and cardiac complications including myoclonus, generalized convulsions, and ventricular arrythmias, with about a 50% mortality rate. Increasing reports of inadvertent intrathecal administration of tranexamic acid prompted the World Health Organization and the Food and Drug Administration to issue medication alerts. 

The inadvertent intrathecal administration of digoxin has been associated with encephalopathy, paraplegia and seizures with about a 50% risk of permanent neurological deficit.

Extreme caution is advised when handling medications during care of a patient in whom a spinal or epidural anesthetic is planned or in those with an indwelling (i.e. epidural or intrathecal) neuraxial catheter. Use of specific neuraxial connectors that are incompatible with other non-neuraxial connectors may help prevent medication errors.

Lastly, the anesthesia professional must understand what medications may be used during shortages and ensure that the medication is compatible with neuraxial administration (i.e. preservative-free).

Appendix: Medications Reported to be Erroneously Administered Neuraxially
Tranexamic acid, digoxin, magnesium sulfate, vasopressors (ephedrine, metaraminol, phenylephrine, norepinephrine), inotropes (dobutamine, dopamine, epinephrine) potassium chloride, labetalol, mexiletine, oxytocin, antibiotics (cefotiam, cefotaxime, clindamycin, piperacillin-tazobactam, rifampicin), contrast agents (diatrizoate meglumine, iothalamate meglumine, ioxaglate sodium, ioxitalamate), muscle relaxants (succinylcholine, vecuronium, cisatracurium, pancuronium), analgesics (paracetamol, tramadol, ketorolac), opioids (remifentanil, hydromorphone), insulin, neostigmine-atropine, metoclopramide, chemotherapeutic agents (bleomycin, doxorubicin, farmorubicin, PEG-asparaginase, vincristine), parenteral nutrition, phenytoin, esomeprazole

*The above list may not include all possible medications or classes of medications that might have been reported in the literature.

References:

1. American Society of Anesthesiologists Committee on Obstetric Anesthesia. ASA Statement on Neuraxial Medication Shortage and Alternatives. Approved by ASA House of Delegates on October 18, 2023.
2. APSF Newsletter June 2024: Unraveling a Recurrent Wrong Drug-Wrong Route Error-Tranexamic Acid in Place of Bupivacaine: A Multistakeholder Approach to Addressing this Important Patient Safety Issue. 
3. Kaur M, Yalla B, Trikha A. Medication errors in a parturient: A huge cost to two lives. J Obstet Anaesth Crit Care 2022; 12:94-98.
4. Moran NF, Bishop DG, Fawcus S, Morris E, Shakur-Still H, Devall AJ, Gallos ID, Widmer M, Oladapo OT, Coomarasamy A, Hofmeyr GJ. Tranexamic acid at cesarean delivery: drug-error deaths. BJOG. 2023;130:114-117.
5. NHS England, Royal College of Anaesthetists, Association of Anaesthetists National Patient Safety Alert – Transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks.NRFit-NatPSA-FINAL-v1.pdf (england.nhs.uk).
6. Patel S. Cardiovascular Drug Administration Errors During Neuraxial Anesthesia or Analgesia-A Narrative Review. J Cardiothorac Vasc Anesth. 2023; 37:291-298.
7. Patel S. Epidural and intrathecal magnesium sulphate administration errors: clinical features and contributing factors. Br J Anaesth. 2023;130:e435-e440. 
8. Patel S, Loveridge R. Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review. Anesth Analg.2015;121:1570-1577.
9. Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019;74:904-914. 
10. Patel S. Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia: A narrative review of 22 recent reports. Eur J Anaesthesiol. 2023;40:334-342.
11. Sharpe EE, Corbett LM, Rollins MD. Medication errors and mitigation strategies in obstetric anesthesia. Curr Opin Anaesthesiol. 2024;37:736-742. 
12. US Food and Drug Administration . FDA alerts healthcare professionals about the risk of medication errors with tranexamic acid injection resulting in inadvertent intrathecal (spinal) injection. 2020. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-healthcare-professionals-about-risk-medication-errors-tranexamic-acid-injection-resulting. Accessed January 5, 2025.
13. Viscusi ER, Hugo V, Hoerauf K, Southwick FS. Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review. Reg Anesth Pain Med. 2021;46:176-181.
14. World Health Organization. Risk of medication errors with tranexamic acid injection resulting in inadvertent intrathecal injection. 2022. Available at https://www.who.int/news/item/16-03-2022-risk-of-medication-errors-with-tranexamic-acid-injection-resulting-in-inadvertent-intrathecal-injection. Accessed January 5, 2025.
15. American Society of Anesthesiologists Committee on Equipment and Facilities. ASA Statement on Labeling of Pharmaceuticals for Use in Anesthesiology. Approved by ASA House of Delegates on October 27, 2004; last amended October 28, 2020.