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KMID : 0357820090330020139
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Korean Journal of Legal Medicine
2009 Volume.33 No. 2 p.139 ~ p.142
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Death After Accidental Injection of Tranexamic Acid During Spinal Anesthesia
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Kim Min-Jung
Jeong Su-Jin
Choi Eun-Seok
Ha Hong-Il
Lee Han-Young
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Abstract
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Medication errors such as administration of wrong drugs, wrong dosage and erroneous route of administration are not rare among medical misadventures. We present an autopsy case of accidental injection of tranexamic acid instead of bupivacaine during spinal anesthesia, accompanying the quantitative result of the tranexamic acid in the blood, cerebrospinal fluid and each internal organs. We think that warning signs on syringes and ampoules, simple and unified guideline for drug administration, separative documentation of drug administration and interpersonal communication on drug information should be done to prevent this type of medical errors.
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KEYWORD
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accidental injection, tranexamic acid, spinal anesthesia, medical misadventure
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