ACCIDENTAL INTRATHECAL TRANEXAMIC ACID ADMINISTRATIONS DURING SPINAL ANAESTHESIA AND THEIR REPORTING IN INDIA – A NARRATIVE REVIEW

Look-alike ampoules of tranexamic acid and local anaesthetic heavy bupivacaine are available, leading to accidental administration. We aimed to investigate India-specific incidents of intrathecal tranexamic acid (TXA) administration during spinal anaesthesia to identify manufacturing issues. Our secondary aim was to determine the availability of any national drug error reporting and monitoring system for hospitals in India. The author investigated published ten reports (11 patients) from India of TXA administration intrathecally in place of heavy bupivacaine. In all mistakes of look-like TXA and local anaesthetic (LA) (heavy 0.5% bupivacaine), ampoules were present in operating rooms. We found three manufacturers who designed, manufactured, and supplied identical TXA and heavy bupivacaine ampules. In addition, there was also a similarity of TXA and LA ampoules among different manufacturers. We searched PubMed and Google Scholar for any publication on India’s national medication error reporting system for hospitals. There was no publication on the national medication safety system involving hospitals. Our study shows intrathecal TXA errors occurred in east-to-west and north-to-south locations. However, there is no national medication error and reporting system to alert health care providers. We highlight potential difficulties and barriers to creating a national mechanism to notify, monitor, and prevent medication errors in hospitals in India.