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PSNet: Patient Safety Network
Journal Article

Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.

Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74(7):904-914.

Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.