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Korean Journal of Legal Medicine 2009;33(2):139-142.
Published online November 30, 2009.
Death After Accidental Injection of Tranexamic Acid During Spinal Anesthesia.
Minjung Kim, Sujin Jeong, Eunseok Choi, Hongil Ha, Han Young Lee
1Division of Forensic Medicine, National Institute of Scientific Investigation, Seoul, Korea. sanchee@korea.kr
2Division of Forensic Toxicology, National Institute of Scientific Investigation, Seoul, Korea.
3Seventh Special Force Brigade, Iksan, Korea.
4Western District Office, National Institute of Scientific Investigation, Jangseong, Korea.
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.
Key Words: accidental injection, tranexamic acid, spinal anesthesia, medical misadventure
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