Accidental infusion of tranexamic acid via a thoracic epidural catheter

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

“…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 Patel 1 who comments on the recent Case Report by Pysyk and Filteau 2 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 The recent years have seen a concerning number of reports of drug errors involving TXA that led to catastrophic outcomes, particularly in the context of neuraxial anesthesia for Cesarean delivery.…”