Neuraxial Medication Administration Errors During Anaesthesia and Perioperative Management, Consequences, Contributing Human and Systemic Factors and Their Prevention: A Systematic Review.

Abstract

Introduction: This systematic review aimed to investigate neuraxial administration errors, examine their contributing factors, and evaluate clinical outcomes using a novel harm scale.

Methods: The author searched PubMed, Web of Science, Scopus, EBSCOhost, and Google Scholar for reports from 1981 to 2025 in any language. Exclusions were reviews, overdose incidents, and non-neuraxial administrations. Harm was classified using a novel five-level scale, and contributing factors were identified using the Human and Systemic Factors Analysis Classification System (HFACS).

Results: The search revealed 50 reports (54 patients), mainly involving the epidural route (38 vs 16 intrathecal), non-obstetric patients (35 vs 17 obstetric), and female gender (73%). Medications were grouped into nine divisions: IV fluids/total parenteral nutrition/insulin, anticholinergics, antiseptics, antiemetics, anticoagulants, non-steroidal anti-inflammatory drugs, opioids, Syntocinon, and others. Atropine (6 patients) was the most common, followed by remifentanil (4), Syntocinon (4), chlorhexidine (3), and water (3). Level 4 events (irreversible paraplegia or quadriplegia, 4 patients) and level 5 events (death, 4 patients) were mostly due to accidental antiseptic bolus administration. Inadvertent neuraxial drug administration occurred at different locations and during various stages of clinical care. The Human Factors Analysis Classification System (HFACS) identified unsafe acts related to skill-based errors and misidentification of routinely used objects. Additional deficiencies included organisational processes, resources, supervision, and task execution for neuraxial anaesthesia or analgesia.

Conclusions: Level 4 and 5 harm was mainly associated with the administration of antiseptic solutions. The HFACS framework-based analysis suggested multiple modifiable institutional and individual deficiencies. Multidisciplinary improvements of organisational safety procedures, relevant preconditions, and neuraxial clinical practices may help prevent these serious incidents.