Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

Reg Anesth Pain Med. 2021 Feb;46(2):176-181. doi: 10.1136/rapm-2020-101836. Epub 2020 Nov 3.


We conducted a search of the literature to identify case reports of neuraxial and peripheral nervous system misconnection events leading to wrong-route medication errors. This narrative review covers a 20-year period (1999-2019; English-language publications and abstracts) and included the published medical literature (PubMed and Embase) and public access documents. Seventy-two documents representing 133 case studies and 42 unique drugs were determined relevant. The most commonly reported event involved administering an epidural medication by an intravenous line (29.2% of events); a similar proportion of events (27.7%) involved administering an intravenous medication by an epidural line. Medication intended for intravenous administration, but delivered intrathecally, accounted for 25.4% of events. In the most serious cases, outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride. These case reports confirm that misconnection events leading to wrong-route errors can occur and may cause serious injury. This comprehensive characterization of events was conducted to better inform clinicians and policymakers, and to describe an emergent strategy designed to mitigate patient risk.

Keywords: anesthesia; drug-related side effects and adverse reactions; injections; local; nerve block; neurotoxicity syndromes; spinal.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Anesthetics, Local*
  • Humans
  • Medication Errors*


  • Anesthetics, Local