{
  "abstract": "Medication Errors in Regional Anesthesia: A Persistent Challenge. Margo Borislavova MD1, Liesbeth Brullot MD2, Steve Coppens MD, PhD2,3 1 Centre Hospitalier Simone Veil, Department of Anesthesiology, France 2 University Hospitals of Leuven, Department of Anesthesiology, Herestraat 49, B-3000, Leuven, Belgium 3 University of Leuven, Biomedical Sciences Group, Department of Cardiovascular Sciences, KU Leuven, B-3000, Leuven, Belgium Background and Objectives Regional anesthesia (RA) plays a key role in modern perioperative care. However, medication errors remain an underrecognized source of harm. This narrative review explores the prevalence, types, contributing factors, and mitigation strategies related to medication errors in RA. Methods We conducted a comprehensive review of literature related to medication errors in regional anesthesia, drawing on audits, surveys, case reports, and patient safety guidelines. A thematic synthesis was used to group errors and prevention strategies. Results Medication errors in RA include preparation, labeling, dose, and route errors. High-risk settings include obstetric anesthesia, combined spinal-epidural techniques, and continuous catheter infusions. Contributing factors span human (cognitive overload, fatigue) and systemic domains (non-standardized drug trays, look-alike packaging). Effective mitigation includes standardized labeling, prefilled syringes, checklists, barcoding, and ISO-compliant spinal connectors. Conclusions Despite advances in safety practices, medication errors in RA remain prevalent. Multimodal prevention strategies, combined with a culture of openness and learning, are essential to reducing patient harm. Introduction Anesthesia practice inherently involves the administration of multiple potent pharmacologic agents, often in time-critical, high-stress environments. While modern anesthetic drugs have transformed perioperative care, their narrow therapeutic windows, variable pharmacodynamics, and high-risk routes of administration make them particularly susceptible to medication errors. 1 2Regional anesthesia techniques are widely regarded as effective, safe, and essential components of multimodal analgesia. However, as the complexity of drug regimens and procedural logistics has increased, so too has the risk of preventable adverse events—particularly medication errors.3 4 These errors, defined by the Institute of Medicine as ‘any preventable event that may cause or lead to inappropriate medication use or harm,’ can occur at various stages: drug preparation, labeling, administration, or documentation. In regional anesthesia, where multiple agents and precise techniques are used in time-sensitive environments, the consequences of such errors can be catastrophic.5 6 This review aims to synthesize current evidence on medication errors in RA, outline contributing factors and high-risk scenarios, and propose evidence-based strategies for prevention. With the expansion of RA in enhanced recovery protocols and opioid-sparing pathways, ensuring medication safety is not merely optional but foundational to quality anesthetic care. Discussion Medication errors in regional anesthesia are often multifactorial, involving both human factors and system-level deficiencies. Although the absolute incidence of these events remains low relative to the number of blocks performed globally, the severity of their consequences—ranging from failed analgesia to permanent neurological damage and death—demands careful scrutiny. These events are rarely caused by a single failure; instead, they typically result from the convergence of multiple latent hazards in the preparation, labeling, or administration phases.1 5 Preparation and labeling errors remain the most frequently reported. In environments where numerous drugs must be prepared under time constraints, such as labor and delivery units or orthopedic block rooms, cognitive overload and interruptions are common. Many of the most devastating cases reported in the literature, such as inadvertent intrathecal injection of tranexamic acid or chlorhexidine, were facilitated by look-alike ampoules, unclear labeling, and failure to implement verification protocols.7 For example, chlorhexidine has been mistaken for bupivacaine, leading to catastrophic outcomes. In one case, a physician inadvertently injected chlorhexidine intrathecally after confusing two unlabelled cups containing clear liquids—normal saline and chlorhexidine—resulting in temporary paraplegia.8 Other cases ended in more devastating circumstances.9 High-risk clinical contexts include obstetric anesthesia, where the pace of work and high turnover increase cognitive strain; combined spinal-epidural techniques, which require simultaneous handling of multiple drugs and equipment; and regional catheter infusions, where concentration, volume, and pump programming must be verified with precision.10 Particularly devastating cases have occurred due to sound-alike, look-alike medication errors involving bupivacaine and tranexamic acid, leading to inadvertent intrathecal administration with catastrophic neurological consequences.11 12 In addition, transition points in care—such as shift handovers or the involvement of trainees—have been linked to increased error likelihood due to lapses in communication or inadequate supervision. Several root causes recur in published reports and audits: • Non-standardized drug trays and ampoule layouts, often leading to misselection. • Unlabeled or ambiguously labeled syringes in sterile fields. • Use of similar-looking containers for dissimilar agents • Delegation of preparation tasks to inexperienced or unsupervised personnel. • Insufficient use of checklists or time-out protocols, even in high-risk blocks. The expanded use of adjuvants in RA, including clonidine, dexamethasone, epinephrine, and dexmedetomidine, introduces further complexity. These drugs are typically drawn into separate syringes and mixed by the proceduralist or assistant, increasing the risk of concentration or dosing errors. Mixing local anesthetic drugs (short/long acting) is not only not necessary, it can also lead to additional errors.13 The use of preservative-containing or incompatible solutions in neuraxial spaces, often due to unfamiliarity or mislabeling, poses additional danger. Furthermore, the use of local anesthetics in varying concentrations (e.g., 0.25% vs. 0.5% bupivacaine) can lead to under- or overdosing, particularly when vials look identical but are stored together. Although human error is an inevitable component of clinical practice, the presence of poorly designed systems amplifies its impact. From a systems perspective, institutions that rely on individual vigilance without embedding safety into workflow are more vulnerable to high-impact events. For example, the absence of color-coded, prefilled syringes forces clinicians to depend on manual drawing and labeling, increasing both time pressure and error risk. Likewise, the absence of double-checking procedures before block performance removes a critical layer of protection against catastrophic drug administration errors.14 Neuraxial-specific NRFit™ connectors, standardized under ISO 80369–6, were developed to reduce the risk of wrong-route medication errors by ensuring that syringes and catheters used for neuraxial or regional procedures are incompatible with standard Luer connectors. Simulation studies and clinical evaluations have demonstrated that NRFit connectors provide comparable performance to Luer systems in terms of flow characteristics, connection integrity, and usability, while significantly reducing the risk of inadvertent intrathecal, epidural, or nerve block administration of non-neuraxial drugs. In response to persistent reports of wrong-route incidents, several national health authorities, including NHS England, have issued safety alerts mandating the transition to NRFit connectors in regional anesthesia practice. However, important limitations remain. NRFit does not prevent the administration of the wrong medication via the correct route. Furthermore, early implementation studies have reported practical concerns, including connector fragility, supply variability, increased dead space, and compatibility issues with existing equipment. These limitations highlight that while NRFit represents an important advancement in medication safety, it must be integrated within a broader multimodal strategy—including proper drug labeling, double-checking protocols, and clinician education—to meaningfully reduce the incidence of neuraxial drug errors.15 A growing body of evidence supports the use of bundled safety interventions to reduce medication errors in anesthesia. In regional anesthesia specifically, practices that are increasingly recommended include: • Prefilled, barcoded syringes for common local anesthetics. • Color-coded ISO-standard syringe labels, used even in sterile environments. • Mandatory time-outs before block performance, including verification of drug, dose, and route. • Use of neuraxial-specific connectors (ISO 80369–6), to prevent wrong-route administration. • Storage segregation of high-risk drugs away from regional anesthesia supplies. Despite the availability of these safety measures, their uptake remains inconsistent, particularly outside academic centers or in resource-limited settings. The reluctance to report medication errors, driven by fear of blame or litigation, further hinders institutional learning. Cultivating a non-punitive culture of safety is essential. Organizations must prioritize the reporting of near misses, recognizing that they offer invaluable opportunities to identify system vulnerabilities before harm occurs. Simulation training offers another avenue for improvement. Incorporating medication error scenarios into RA simulation allows teams to rehearse recognition and response, while reinforcing standard operating procedures. Competency-based curricula should include modules on drug safety, ampoule recognition, and label interpretation, particularly for trainees. Finally, the growing interest in artificial intelligence and real-time clinical decision support systems may, in the future, help detect pattern deviations (e.g., unusual syringe labeling, incompatible combinations) and issue alerts. Until such systems become commonplace, however, the burden remains on providers and institutions to build layers of defense that make errors difficult to initiate and easy to intercept.16 Conclusion Medication errors in regional anesthesia, though uncommon, can result in devastating patient outcomes. Their causes are multifactorial, involving human factors, systemic vulnerabilities, and process failures. Recognizing high-risk settings, standardizing practice, and embracing technological and cultural solutions are key to mitigation. As RA becomes increasingly central to modern surgical care, ensuring the safe and accurate administration of drugs must be prioritized as a core component of patient safety. Anesthesia teams must remain vigilant, proactive, and committed to continuous learning to eliminate preventable harm.References Wahr JA, et al. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth. 2017;118:32–43.Kim JY, et al. Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS. Anaesth Intensive Care 2022;50:204–219.Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial block: report on the third national audit project of the royal college of anaesthetists. Br J Anaesth. 2009;102:179–190.Beckers A, Verelst P, van Zundert A. Inadvertent epidural injection of drugs for intravenous use. A review. Acta Anaesthesiol Belg. 2012;63:75–9.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.Maltby JR, Hutter CD, Clayton KC. The woolley and roe case. Br J Anaesth. 2000;84:121–126.Bryan R, Aronson JK, Williams A, Jordan S. The problem of look-alike, sound-alike name errors: drivers and solutions. Br J Clin Pharmacol. 2021;87:386–394.Douqchi B, et al. Neurotoxic myelitis following accidental epidural injection of chlorhexidine during obstetric epidural anesthesia: a case report. Cureus 2025;17:e84299.Bogod D. The sting in the tail: antiseptics and the neuraxis revisited. Anaesthesia 2012;67:1305–1309.Patel S, Loveridge R. Obstetric neuraxial drug administration errors. Anesth Analg. 2015;121:1570–1577. Kaabachi O, Eddhif M, Rais K, Zaabar M. Inadvertent intrathecal injection of tranexamic acid. Saudi J Anaesth. 2011;5:90.Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia 2019;74:904–914.Gadsden J, et al. The effect of mixing 1.5% mepivacaine and 0.5% bupivacaine on duration of analgesia and latency of block onset in ultrasound-guided interscalene block. Anesth Analg. 2011;112:471–476.Hew CM, Cyna AM, Simmons SW. Avoiding inadvertent epidural injection of drugs intended for non-epidural use. Anaesth Intensive Care. 2003;31:44–49.Merry AF, Shipp DH, Lowinger JS. The contribution of labelling to safe medication administration in anaesthetic practice. Best Pract Res Clin Anaesthesiol. 2011;25:145–159.Ye J. Patient safety of perioperative medication through the lens of digital health and artificial intelligence. JMIR Perioper Med. 2023;6:e34453.",
  "authors": [
    {
      "affiliations": [
        "Department of Anesthesiology, Centre Hospitalier Simone Veil, Department of Anesthesiology, France, Paris, France"
      ],
      "name": "Borislavova Margarita"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, Unversity Hospitals of Leuven, Leuven, Belgium"
      ],
      "name": "Liesbeth Brullot"
    },
    {
      "affiliations": [
        "Department of Anesthesiology, Unversity Hospitals of Leuven, Leuven, Belgium"
      ],
      "name": "Steve Coppens"
    }
  ],
  "title": "FT45 Medication errors in regional anesthesia: a persistent challenge",
  "uid": "d815af97-95c5-5894-be1c-b7a8537f76b9"
}