nach oben

Canadian Journal of Anesthesia/Journal canadien d'anesthésie

Erschienen in:

14.03.2023 | Editor’s Note

One week in the life of my anesthetic cart’s medication drawer or: drug errors—what (else) will it take to change the system?

verfasst von: Stephan K. W. Schwarz, MD, PhD, FRCPC

Erschienen in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Ausgabe 5/2023

Einloggen, um Zugang zu erhalten

Excerpt

It is not every day that a Letter to the Editor is accompanied by an Editorial in the Journal. Nevertheless, on the occasion of a Correspondence section piece in this month’s issue by Patel¹ who comments on the recent Case Report by Pysyk and Filteau² of accidental epidural injection of tranexamic acid (TXA), we feature an Editorial by Orser et al. who provide further scholarly insight and thoughtful commentary on both articles and summarize evidence-based recommendations for the prevention of such drug errors.³ …

World Health Organization. Updated WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage, 2017. Available at URL: https://apps.who.int/iris/bitstream/handle/10665/259379/WHO-RHR-17.21-eng.pdf (accessed February 2023).

World Health Organization. Risk of medication errors with tranexamic acid injection resulting in inadvertent intrathecal injection, 2022. Available at URL: https://www.who.int/news/item/16-03-2022-risk-of-medication-errors-with-tranexamic-acid-injection-resulting-in-inadvertent-intrathecal-injection (accessed February 2023).

U.S. 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 URL: https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-healthcare-professionals-about-risk-medication-errors-tranexamic-acid-injection-resulting (accessed February 2023).

Institute for Safe Medication Practices Canada. ALERT: Substitution error with tranexamic acid during spinal anesthesia, 2022. Available at URL: https://ismpcanada.ca/wp-content/uploads/ISMPCSB2022-i6-Tranexamic-Acid-Spinal-Anesthesia.pdf (accessed February 2023).

Institute for Safe Medication Practices. NRFit: A global “fit” for neuraxial medication safety, 2020. Available from URL: https://www.ismp.org/resources/nrfit-global-fit-neuraxial-medication-safety (accessed February 2023).

Canadian Anesthesiologists’ Society. Available at URL: https://www.cas.ca/en/meetings-events/webinars-virtual/cas-medication-safety-webinar (accessed February 2023).

Organisation mondiale de la Santé. Updated WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage, 2017 Disponible (en anglais) à l’adresse URL : https://apps.who.int/iris/bitstream/handle/10665/259379/WHO-RHR-17.21-eng.pdf (consulté en février 2023).

Organisation mondiale de la Santé. Risk of medication errors with tranexamic acid injection resulting in inadvertent intrathecal injection, 2022. Disponible (en anglais) à l’adresse URL : https://www.who.int/news/item/16-03-2022-risk-of-medication-errors-with-tranexamic-acid-injection-resulting-in-inadvertent-intrathecal-injection (consulté en février 2023).

U.S. 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. Disponible (en anglais) à l’adresse URL : https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-healthcare-professionals-about-risk-medication-errors-tranexamic-acid-injection-resulting (consulté en février 2023).

Institut pour la sécurité des médicaments aux patients du Canada. ALERTE: Erreur de substitution impliquant l’acide tranexamique pendant une anesthésie rachidienne, 2022. Disponible à l’adresse URL : https://ismpcanada.ca/wp-content/uploads/BISMPC2022-n6-acide-tranexamique.pdf (consulté en février 2023).

Institute for Safe Medication Practices. NRFit : A global “fit” for neuraxial medication safety, 2020. Disponible (en anglais) à partir de l’URL: https://www.ismp.org/resources/nrfit-global-fit-neuraxial-medication-safety (consulté en février 2023).

Société canadienne des anesthésiologistes.Disponible (en anglais) à l’adresse URL : https://www.cas.ca/en/meetings-events/webinars-virtual/cas-medication-safety-webinar (consulté en février 2023).

Patel S. Accidental infusion of tranexamic acid via a thoracic epidural catheter. Can J Anesth 2023; https://doi.org/10.1007/s12630-023-02435-0.

Pysyk CL, Filteau L. Accidental administration of tranexamic acid into the epidural space: a case report. Can J Anesth 2022; 69: 1169–73. https://doi.org/10.1007/s12630-022-02276-3CrossRefPubMed

Orser BA, Hyland S, Byrick R. Preventing neuraxial administration of tranexamic acid. Can J Anesth 2023; https://doi.org/10.1007/s12630-023-02434-1

Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia 2019; 74: 904–14. https://doi.org/10.1111/anae.14662CrossRefPubMed

Grissinger M. Death and neurological devastation from intrathecal vinca alkaloids. P T 2016; 41: 464–525.PubMedPubMedCentral

Orser BA, Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anesth 2001; 48: 139–46. https://doi.org/10.1007/BF03019726.CrossRefPubMed

Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence-based strategies for preventing drug errors during anaesthesia. Anaesthesia 2004; 59: 493–504. https://doi.org/10.1111/j.1365-2044.2004.03670.xCrossRefPubMed

Glavin RJ. Drug errors: consequences, mechanisms, and avoidance. Br J Anaesth 2010; 105: 76–82. https://doi.org/10.1093/bja/aeq131CrossRefPubMed

Titel: One week in the life of my anesthetic cart’s medication drawer or: drug errors—what (else) will it take to change the system?
verfasst von: Stephan K. W. Schwarz, MD, PhD, FRCPC
Publikationsdatum: 14.03.2023
Verlag: Springer International Publishing
Erschienen in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Ausgabe 5/2023
Print ISSN: 0832-610X
Elektronische ISSN: 1496-8975
DOI: https://doi.org/10.1007/s12630-023-02437-y

Neu im Fachgebiet AINS

18.04.2024 | Wirbelsäulenmetastase | Nachrichten

Update AINS

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

hier abonnieren

Live-Webinar: Aktuelle Leitlinien bei Herz-Kreislauf-Erkrankungen

Springer Medizin

One week in the life of my anesthetic cart’s medication drawer or: drug errors—what (else) will it take to change the system?

Excerpt

Neu im Fachgebiet AINS

Stereotaktische Radiatio schlägt konventionelle Bestrahlung

Fünf Dinge, die im Kindernotfall besser zu unterlassen sind

Hochrisiko-Eingriffe für postoperative Übelkeit

Diclofenac-Gel versus Ibuprofen bei akuten Rückenschmerzen

Update AINS

Live-Webinar: Aktuelle Leitlinien bei Herz-Kreislauf-Erkrankungen

Springer Medizin

Excerpt

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 5/2023

Accidental infusion of tranexamic acid via a thoracic epidural catheter

A hood shield reduces postdoffing contamination during simulated COVID-19 airway management: an exploratory, simulation-based randomized study

Preventing neuraxial administration of tranexamic acid

A randomized controlled trial comparing three supraglottic airway devices used as a conduit to facilitate tracheal intubation with flexible bronchoscopy

Effects of melatonin on postoperative sleep quality: a systematic review, meta-analysis, and trial sequential analysis

Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral

Neu im Fachgebiet AINS

Stereotaktische Radiatio schlägt konventionelle Bestrahlung

Fünf Dinge, die im Kindernotfall besser zu unterlassen sind

Hochrisiko-Eingriffe für postoperative Übelkeit

Diclofenac-Gel versus Ibuprofen bei akuten Rückenschmerzen

Update AINS