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vol.109 issue11Changing priorities in maternal and perinatal health in Gert Sibande District, South AfricaSending patients electronic reminders on the need for urgent treatment to prevent life-threatening illnesses: Some lessons to be learned and a cautionary reminder author indexsubject indexarticles search
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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

Abstract

BISHOP, D G et al. Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error. SAMJ, S. Afr. med. j. [online]. 2019, vol.109, n.11, pp.841-844. ISSN 2078-5135.  http://dx.doi.org/10.7196/samj.2019.v109i11.14242.

The National Committee on Confidential Enquiries into Maternal Deaths recently received notification of a death in South Africa caused by inadvertent intrathecal administration of tranexamic acid (TXA). TXA is increasingly used during caesarean delivery following updated recommendations from the World Health Organization in 2017. However, its greater availability has led to an international rise in drug errors during obstetric spinal anaesthesia. This case highlights a growing clinical risk, of which all operating theatre staff should be aware. Review of existing operating theatre drug handling practices is required in order to decrease this risk. Recommendations are made that aim to minimise drug errors associated with the use of this potentially life-saving intervention.

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