{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T18:35:14Z","timestamp":1791484514919,"version":"4.3.4"},"reference-count":103,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2020,11,3]],"date-time":"2020-11-03T00:00:00Z","timestamp":1604361600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Becton Dickenson and Company","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2020,9,29]]},"published-print":{"date-parts":[[2021,2]]},"abstract":"<jats:p>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\u20132019; 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.<\/jats:p>","DOI":"10.1136\/rapm-2020-101836","type":"journal-article","created":{"date-parts":[[2020,11,4]],"date-time":"2020-11-04T03:05:17Z","timestamp":1604459117000},"page":"176-181","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":26,"title":["Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review"],"prefix":"10.1136","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0260-4396","authenticated-orcid":false,"given":"Eugene R","family":"Viscusi","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vincent","family":"Hugo","sequence":"additional","affiliation":[{"name":"Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Klaus","family":"Hoerauf","sequence":"additional","affiliation":[{"name":"Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA"},{"name":"Department of Anesthesiology and Intensive Care Medicine, Medical University of Vienna, Wien, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frederick S","family":"Southwick","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Florida, Gainesville, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,11,3]]},"reference":[{"key":"2025101109490480000_46.2.176.1","unstructured":"Choi J , Gadsden J . Local anesthetic mixtures for peripheral nerve blocks. In: Hadzic A , ed. Hadzic\u2019s Textbook of Regional Anesthesia and Acute Pain Management. 2nd edn. New York: McGraw-Hill Education, 2017."},{"key":"2025101109490480000_46.2.176.2","unstructured":"Toledano RD , Van de Velde M . Epidural anesthesia and analgesia. In: Hadzic A , ed. Hadzic\u2019s Textbook of Regional Anesthesia and Acute Pain Management. 2nd edn. New York: McGraw-Hill Education, 2017."},{"key":"2025101109490480000_46.2.176.3","unstructured":"US Food and Drug Administration . Reducing risks through standards development for medical device connectors. Silver Spring, MD. Available: https:\/\/www.fda.gov\/medical-devices\/medical-device-connectors\/reducing-risks-through-standards-development-medical-device-connectors [Accessed September 22, 2020]."},{"key":"2025101109490480000_46.2.176.4","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1111\/pan.13279","article-title":"New solutions to reduce wrong route medication errors","volume":"28","author":"Litman","year":"2018","journal-title":"Pediatr Anaesth"},{"key":"2025101109490480000_46.2.176.5","unstructured":"US Food and Drug Administration. . Medical device connectors. Available: https:\/\/www.fda.gov\/medical-devices\/general-hospital-devices-and-supplies\/medical-device-connectors [Accessed September 22, 2020]."},{"key":"2025101109490480000_46.2.176.6","doi-asserted-by":"crossref","first-page":"1570","DOI":"10.1213\/ANE.0000000000000938","article-title":"Obstetric neuraxial drug administration errors: a quantitative and qualitative analytical review","volume":"121","author":"Patel","year":"2015","journal-title":"Anesth Analg"},{"key":"2025101109490480000_46.2.176.7","doi-asserted-by":"crossref","first-page":"382","DOI":"10.1016\/j.jen.2014.03.010","article-title":"Mix-ups and misconnections: avoiding intravenous line errors","volume":"40","author":"Paparella","year":"2014","journal-title":"J Emerg Nurs"},{"key":"2025101109490480000_46.2.176.8","first-page":"75","article-title":"Inadvertent epidural injection of drugs for intravenous use: a review.","volume":"63","author":"Beckers","year":"2012","journal-title":"Acta Anaesthesiol Belg"},{"key":"2025101109490480000_46.2.176.9","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1179\/joc.2010.22.2.83","article-title":"Errors involving patients receiving intrathecal chemotherapy","volume":"22","author":"Scalzone","year":"2010","journal-title":"J Chemother"},{"key":"2025101109490480000_46.2.176.10","doi-asserted-by":"crossref","first-page":"559","DOI":"10.4103\/0970-9185.74616","article-title":"Inadvertent injection of piperacillin-tazobactum into epidural space","volume":"26","author":"Agarwal","year":"2010","journal-title":"J Anaesthesiol Clin Pharmacol"},{"key":"2025101109490480000_46.2.176.11","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1017\/S0265021502241009","article-title":"Accidental injection of intravenous bupivacaine","volume":"19","author":"Karaca","year":"2002","journal-title":"Eur J Anaesthesiol"},{"key":"2025101109490480000_46.2.176.12","first-page":"34","article-title":"Epidural medications given intravenously may result in death","volume":"18","author":"Koczmara","year":"2007","journal-title":"Dynamics"},{"key":"2025101109490480000_46.2.176.13","doi-asserted-by":"crossref","first-page":"1130","DOI":"10.3171\/2013.2.JNS121712","article-title":"Complex imaging features of accidental cerebral intraventricular gadolinium administration","volume":"118","author":"Nayak","year":"2013","journal-title":"J Neurosurg"},{"key":"2025101109490480000_46.2.176.14","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1213\/XAA.0000000000000239","article-title":"Unintentional infusion of phenylephrine into the epidural space","volume":"6","author":"Townley","year":"2016","journal-title":"A A Case Rep"},{"key":"2025101109490480000_46.2.176.15","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijoa.2005.06.009"},{"key":"2025101109490480000_46.2.176.16","first-page":"343","article-title":"Accidental intraventricular administration of phenytoin through an external ventricular drain: case report","volume":"20:347","author":"McConnell","year":"2011","journal-title":"Am J Crit Care"},{"key":"2025101109490480000_46.2.176.17","first-page":"S39","article-title":"Drug-related critical incidents in a multidisciplinary intensive care unit [abstract 0127]","volume":"40","author":"Morrison","year":"2014","journal-title":"Intensive Care Med"},{"key":"2025101109490480000_46.2.176.18","first-page":"1","article-title":"Managing risk during transition to new ISO tubing connector standards","volume":"53","year":"2014","journal-title":"Sentinel Event Alert"},{"key":"2025101109490480000_46.2.176.19","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1016\/j.forsciint.2009.05.014","article-title":"Medical negligence in drug associated deaths","volume":"190","author":"Madea","year":"2009","journal-title":"Forensic Sci Int"},{"key":"2025101109490480000_46.2.176.20","doi-asserted-by":"publisher","DOI":"10.1177\/0884533611406134"},{"key":"2025101109490480000_46.2.176.21","doi-asserted-by":"crossref","first-page":"494","DOI":"10.1177\/0310057X0102900508","article-title":"The frequency and nature of drug administration error during anaesthesia","volume":"29","author":"Webster","year":"2001","journal-title":"Anaesth Intensive Care"},{"key":"2025101109490480000_46.2.176.22","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1097\/00129804-200601000-00005","article-title":"An overview of intravenous-related medication administration errors as reported to MEDMARX\u00ae, a national medication error-reporting program","volume":"29","author":"Hicks","year":"2006","journal-title":"J Infus Nurs"},{"key":"2025101109490480000_46.2.176.23","doi-asserted-by":"publisher","DOI":"10.1111\/j.1460-9592.2010.03421.x"},{"key":"2025101109490480000_46.2.176.24","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2044.2005.04123.x"},{"key":"2025101109490480000_46.2.176.25","doi-asserted-by":"publisher","DOI":"10.1007\/s00540-008-0624-4"},{"key":"2025101109490480000_46.2.176.26","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1177\/0310057X0903700105","article-title":"Drug administration errors: a prospective survey from three South African teaching hospitals","volume":"37","author":"Llewellyn","year":"2009","journal-title":"Anaesth Intensive Care"},{"key":"2025101109490480000_46.2.176.27","first-page":"823","article-title":"Management of medication errors associated with the intrathecal administration instead of intravenous administration at the French agency (ANSM) [abstract ISP3501-37]","volume":"36","author":"Martin-Brisac","year":"2013","journal-title":"Drug Saf"},{"key":"2025101109490480000_46.2.176.28","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2044.2012.07154.x"},{"key":"2025101109490480000_46.2.176.29","first-page":"63","article-title":"Reducing risk of epidural-intravenous misconnections","volume":"26","author":"Block","year":"2012","journal-title":"APSF Newsletter"},{"key":"2025101109490480000_46.2.176.30","first-page":"47","article-title":"Clinical experience with capnography monitoring for PCA patients","volume":"26","author":"Maddox","year":"2012","journal-title":"APSF Newsletter"},{"key":"2025101109490480000_46.2.176.31","unstructured":"World Health Organization . Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres. Geneva, Switzerland: World Health Organization, 2014."},{"key":"2025101109490480000_46.2.176.32","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2007.025767"},{"key":"2025101109490480000_46.2.176.33","doi-asserted-by":"publisher","DOI":"10.2146\/ajhp160848"},{"key":"2025101109490480000_46.2.176.34","doi-asserted-by":"publisher","DOI":"10.1046\/j.1460-9592.2000.00580.x"},{"key":"2025101109490480000_46.2.176.35","doi-asserted-by":"publisher","DOI":"10.1046\/j.1460-9592.2002.0787f.x"},{"key":"2025101109490480000_46.2.176.36","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1213\/01.ANE.0000096008.24193.05","article-title":"Grand mal convulsion after an accidental intravenous injection of ropivacaine","volume":"98","author":"Dernedde","year":"2004","journal-title":"Anesth Analg"},{"key":"2025101109490480000_46.2.176.37","unstructured":"National Health Service . Patient Safety Alert 21: Safer practice with epidural injections and infusions. London, United Kingdom. Available: https:\/\/www.sps.nhs.uk\/wp-content\/uploads\/2018\/02\/2007-NRLS-0396-Epidural-injectns-PSA-2007-03-28-v1.pdf [Accessed 22 Sep 2020]."},{"key":"2025101109490480000_46.2.176.38","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aen360"},{"key":"2025101109490480000_46.2.176.39","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1111\/j.1399-6576.2012.02762.x","article-title":"The frequency and nature of drug administration error during anaesthesia in a Chinese hospital","volume":"57","author":"Zhang","year":"2013","journal-title":"Acta Anaesthesiol Scand"},{"key":"2025101109490480000_46.2.176.40","unstructured":"Health Quality & Safety Commission New Zealand . Epidural medicines through intravenous lines. Available: https:\/\/www.hqsc.govt.nz\/assets\/Reportable-Events\/Publications\/Open-book\/OB-epidural-medications-intravenous.pdf [Accessed September 22, 2020]."},{"key":"2025101109490480000_46.2.176.41","first-page":"426","article-title":"Accidental epidural or intrathecal administration of thiocolchicoside can be lethal [abstract 130]","volume":"54","author":"Lonati","year":"2016","journal-title":"Clin Toxicol"},{"key":"2025101109490480000_46.2.176.42","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1097\/01.ASM.0001072584.20118.9f","article-title":"A case report from the anesthesia incident reporting system","volume":"79","year":"2015","journal-title":"ASA Monitor"},{"key":"2025101109490480000_46.2.176.43","doi-asserted-by":"crossref","DOI":"10.1097\/00003643-201406001-00505","article-title":"\u201cEternal vigilance is the price of safety\u201d: a case of inadvertent administration of oxytocin via epidural catheter","volume":"31","author":"Chowdhury","year":"2014","journal-title":"Eur J Anaesthesiol"},{"key":"2025101109490480000_46.2.176.44","doi-asserted-by":"crossref","first-page":"1128","DOI":"10.1111\/j.1460-9592.2005.01584.x","article-title":"Inadvertent epidural infusion of paracetamol in a child","volume":"15","author":"Courreges","year":"2005","journal-title":"Paediatr Anaesth"},{"key":"2025101109490480000_46.2.176.45","first-page":"595","article-title":"Inadvertent epidural infusion of paracetamol in an elderly patient","volume":"6","author":"Dehne","year":"2011","journal-title":"Central European Journal of Medicine"},{"key":"2025101109490480000_46.2.176.46","doi-asserted-by":"crossref","DOI":"10.1016\/j.jclinane.2011.01.015","article-title":"Prolonged neuromuscular block after an accidental epidural injection of vecuronium","volume":"23","author":"Furuya","year":"2011","journal-title":"J Clin Anesth"},{"key":"2025101109490480000_46.2.176.47","first-page":"239","article-title":"Intravenous propofol precipitates the hypotension induced by inadvertent epidural thiopental injection","volume":"44","author":"Huang","year":"2006","journal-title":"Acta Anaesthesiol Taiwan"},{"key":"2025101109490480000_46.2.176.48","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1111\/j.1365-2044.2007.04996.x","article-title":"Inadvertent epidural administration of insulin","volume":"62","author":"Kal","year":"2007","journal-title":"Anaesthesia"},{"key":"2025101109490480000_46.2.176.49","doi-asserted-by":"crossref","first-page":"137","DOI":"10.4103\/joacp.JOACP_19_17","article-title":"Inadvertent administration of potassium chloride in the epidural space: how to prevent the inevitable","volume":"35","author":"Kaur","year":"2019","journal-title":"J Anaesthesiol Clin Pharmacol"},{"key":"2025101109490480000_46.2.176.50","doi-asserted-by":"crossref","first-page":"1550","DOI":"10.1097\/00000539-200012000-00046","article-title":"Accidental epidural injection of vecuronium","volume":"91","author":"Kostopanagiotou","year":"2000","journal-title":"Anesth Analg"},{"key":"2025101109490480000_46.2.176.51","doi-asserted-by":"crossref","first-page":"1546","DOI":"10.1213\/01.ANE.0000151471.73967.52","article-title":"Accidental epidural injection of pancuronium","volume":"100","author":"Krataijan","year":"2005","journal-title":"Anestha Analg"},{"key":"2025101109490480000_46.2.176.52","doi-asserted-by":"crossref","DOI":"10.1186\/s12871-017-0425-0","article-title":"Acute transient spinal paralysis and cardiac symptoms following an accidental epidural potassium infusion \u2013 a case report","volume":"17","author":"Kreutztr\u00e4ger","year":"2017","journal-title":"BMC Anesthesiol"},{"key":"2025101109490480000_46.2.176.53","doi-asserted-by":"publisher","DOI":"10.1007\/s001010050803"},{"key":"2025101109490480000_46.2.176.54","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1097\/00003643-200110000-00010","article-title":"Inadvertent infusion of a high dose of potassium chloride via a thoracic epidural catheter","volume":"18","author":"Litz","year":"2001","journal-title":"Eur J Anaesthesiol"},{"key":"2025101109490480000_46.2.176.55","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1186\/s40981-016-0046-5","article-title":"Accidental administration of the remifentanil formulation Ultiva\u2122 into the epidural space and the complete time course of its consequences: a case report","volume":"2","author":"Nishimoto","year":"2016","journal-title":"JA Clin Rep"},{"key":"2025101109490480000_46.2.176.56","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1016\/j.ijoa.2003.07.002","article-title":"Accidental epidural injection of ephedrine","volume":"13","author":"Olmez","year":"2004","journal-title":"Int J Obstet Anesth"},{"key":"2025101109490480000_46.2.176.57","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1016\/j.bjan.2014.10.007","article-title":"[Inadvertent injection of succinylcholine as an epidural test dose]","volume":"67","author":"Pourzitaki","year":"2017","journal-title":"Rev Bras Anestesiol"},{"key":"2025101109490480000_46.2.176.58","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1016\/j.ijoa.2012.02.001","article-title":"Accidental epidural administration of Syntocinon","volume":"21","author":"Ross","year":"2012","journal-title":"Int J Obstet Anesth"},{"key":"2025101109490480000_46.2.176.59","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/j.jclinane.2003.07.001","article-title":"Inadvertent epidural injection of ephedrine in labor","volume":"16","author":"Sidi","year":"2004","journal-title":"J Clin Anesth"},{"key":"2025101109490480000_46.2.176.60","doi-asserted-by":"crossref","first-page":"1139","DOI":"10.1213\/01.ane.0000198636.22059.f0","article-title":"Accidental epidural administration of succinylcholine","volume":"102","author":"Sofianou","year":"2006","journal-title":"Anesth Analg"},{"key":"2025101109490480000_46.2.176.61","first-page":"1429","article-title":"[Accidental epidural administration of vecuronium]","volume":"56","author":"Tabuchi","year":"2007","journal-title":"Masui"},{"key":"2025101109490480000_46.2.176.62","first-page":"191","article-title":"Inadvertent infusion of potassium chloride via an epidural catheter","volume":"58","author":"van der Steeg","year":"2007","journal-title":"Acta Anaesthesiol Belg"},{"key":"2025101109490480000_46.2.176.63","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1097\/00003643-200408000-00017","article-title":"Inadvertent epidural administration of cisatracurium","volume":"21","author":"Vassilakos","year":"2004","journal-title":"Eur J Anaesthesiol"},{"key":"2025101109490480000_46.2.176.64","first-page":"69","article-title":"Accidental injection of thiopental into the epidural space","volume":"17","author":"Weigert","year":"2000","journal-title":"Eur J Anaesthesiol"},{"key":"2025101109490480000_46.2.176.65","doi-asserted-by":"crossref","first-page":"273","DOI":"10.5152\/TJAR.2014.92300","article-title":"Inadvertent administration of neostigmine-atropine mixture from epidural catheter","volume":"42","author":"Yuksel Yildirim","year":"2014","journal-title":"Turk J Anesthesiol Reanim"},{"key":"2025101109490480000_46.2.176.66","first-page":"448","article-title":"Peridural accidental administration of xenobiotics: an unpredictable outcome [abstract 180]","volume":"54","author":"Lonati","year":"2016","journal-title":"Clin Toxicol"},{"key":"2025101109490480000_46.2.176.67","doi-asserted-by":"publisher","DOI":"10.1007\/s003810050338"},{"key":"2025101109490480000_46.2.176.68","doi-asserted-by":"publisher","DOI":"10.1081\/CLT-120014647"},{"key":"2025101109490480000_46.2.176.69","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1097\/WNQ.0b013e318275e2f2","article-title":"Inadvertent intrathecal injection of inappropriate ionic contrast media for myelography","volume":"23","author":"Azarpira","year":"2013","journal-title":"Neurosurg Q"},{"key":"2025101109490480000_46.2.176.70","doi-asserted-by":"crossref","first-page":"340","DOI":"10.1016\/j.ijoa.2005.02.005","article-title":"Inadvertent intrathecal injection of labetalol in a patient undergoing post-partum tubal ligation","volume":"14","author":"Balestrieri","year":"2005","journal-title":"Int J Obstet Anesth"},{"key":"2025101109490480000_46.2.176.71","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aeg265"},{"key":"2025101109490480000_46.2.176.72","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1007\/s00228-004-0787-3","article-title":"Accidental intrathecal infusion of cefotiam: clinical presentation and management","volume":"60","author":"Brossner","year":"2004","journal-title":"Eur J Clin Pharmacol"},{"key":"2025101109490480000_46.2.176.73","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1159\/000441380","article-title":"Two fatal cases of accidental intrathecal vincristine administration: learning from death events","volume":"61","author":"Chotsampancharoen","year":"2016","journal-title":"Chemotherapy"},{"key":"2025101109490480000_46.2.176.74","first-page":"310","article-title":"Accidental intrathecal administration of bleomycin: favourable outcome after cerebrospinal fluid exchange [abstract 163]","volume":"53","author":"Cottin","year":"2015","journal-title":"Clin Toxicol"},{"key":"2025101109490480000_46.2.176.75","doi-asserted-by":"publisher","DOI":"10.1097\/PAF.0b013e3181c21c10"},{"key":"2025101109490480000_46.2.176.76","doi-asserted-by":"publisher","DOI":"10.1016\/S0379-0738(01)00394-2"},{"key":"2025101109490480000_46.2.176.77","doi-asserted-by":"publisher","DOI":"10.1097\/MPH.0b013e3181b83fba"},{"key":"2025101109490480000_46.2.176.78","doi-asserted-by":"crossref","first-page":"108","DOI":"10.5144\/0256-4947.2002.108","article-title":"Intrathecal vincristine: long-term survivor of potentially fatal chemotherapeutic error","volume":"22","author":"Iqbal","year":"2002","journal-title":"Ann Saudi Med"},{"key":"2025101109490480000_46.2.176.79","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1038\/sj.sc.3101592","article-title":"Neurological improvement and rehabilitation potential following toxic myelopathy due to intrathecal injection of doxorubicin","volume":"42","author":"Jordan","year":"2004","journal-title":"Spinal Cord"},{"key":"2025101109490480000_46.2.176.80","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1097\/00000446-200601000-00023","article-title":"Vincristine: right drug, wrong route","volume":"106","author":"Karch","year":"2006","journal-title":"Am J Nurs"},{"key":"2025101109490480000_46.2.176.81","first-page":"926","article-title":"Inadvertent administration of intrathecal tranexamic acid [abstract 20]","volume":"56","author":"Koch","year":"2018","journal-title":"Clin Toxicol"},{"key":"2025101109490480000_46.2.176.82","doi-asserted-by":"crossref","first-page":"688","DOI":"10.3346\/jkms.1999.14.6.688","article-title":"Neural toxicity induced by accidental intrathecal vincristine administration","volume":"14","author":"Kwack","year":"1999","journal-title":"J Korean Med Sci"},{"key":"2025101109490480000_46.2.176.83","doi-asserted-by":"publisher","DOI":"10.1177\/197140091202500212"},{"key":"2025101109490480000_46.2.176.84","doi-asserted-by":"crossref","first-page":"S180","DOI":"10.1016\/j.pmrj.2010.07.445","article-title":"Managing spinal cord injury caused by inadvertent intrathecal vincristine in a patient with T-cell acute lymphoblastic leukemia: a case report [abstract]","volume":"2","author":"Miranda","year":"2010","journal-title":"PM R"},{"key":"2025101109490480000_46.2.176.85","first-page":"602","article-title":"Intrathecal insult with iothalamate meglumine [abstract 64]","volume":"50","author":"Nelson","year":"2012","journal-title":"Clin Toxicol"},{"key":"2025101109490480000_46.2.176.86","first-page":"682","article-title":"Physostigmine reversal of baclofen? Inadvertent administration of intrathecal physostigmine [abstract 94]","volume":"53","author":"Olives","year":"2015","journal-title":"Clin Toxicol"},{"key":"2025101109490480000_46.2.176.87","first-page":"S258","article-title":"Inadvertent intrathecal vincristine administration: report of a fatal case despite cerebrospinal fluid lavage and a review of the literature","volume":"94","author":"Pongudom","year":"2011","journal-title":"J Med Assoc Thai"},{"key":"2025101109490480000_46.2.176.88","doi-asserted-by":"publisher","DOI":"10.3171\/spi.2007.6.3.280"},{"key":"2025101109490480000_46.2.176.89","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1007\/s12288-016-0666-y","article-title":"Clinical presentation of inadvertent intrathecal vincristine masquerading Guillain\u2013Barre syndrome","volume":"32","author":"Saha","year":"2016","journal-title":"Indian J Hematol Blood Transfus"},{"key":"2025101109490480000_46.2.176.90","doi-asserted-by":"crossref","DOI":"10.1111\/j.1365-2125.2005.02405.x","article-title":"Inadvertent intrathecal administration of rifampicin","volume":"60","author":"Senbaga","year":"2005","journal-title":"Br J Clin Pharmacol"},{"key":"2025101109490480000_46.2.176.91","doi-asserted-by":"crossref","first-page":"S86","DOI":"10.1007\/s00330-002-1417-z","article-title":"Inadvertent intrathecal use of ionic contrast agent","volume":"12","author":"van der Leede","year":"2002","journal-title":"Eur Radiol"},{"key":"2025101109490480000_46.2.176.92","doi-asserted-by":"publisher","DOI":"10.1097\/00000542-200301000-00042"},{"key":"2025101109490480000_46.2.176.93","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1213\/XAA.0000000000000230","article-title":"Misconnections in the critically ill: injection of high-dose gadolinium into an external ventricular drain","volume":"6","author":"Singh","year":"2016","journal-title":"A A Case Rep"},{"key":"2025101109490480000_46.2.176.94","doi-asserted-by":"crossref","DOI":"10.1097\/MPH.0b013e3181dccc39","article-title":"Inadvertent intrathecal injection of PEG-asparaginase","volume":"32","author":"Naqvi","year":"2010","journal-title":"J Pediatr Hematol Oncol"},{"key":"2025101109490480000_46.2.176.95","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1007\/s00586-002-0504-9","article-title":"Accidental intrathecal mercury application","volume":"13","author":"Stark","year":"2004","journal-title":"Eur Spine J"},{"key":"2025101109490480000_46.2.176.96","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2008.030874"},{"key":"2025101109490480000_46.2.176.97","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1177\/0310057X0303100108","article-title":"Avoiding inadvertent epidural injection of drugs intended for non-epidural use","volume":"31","author":"Hew","year":"2003","journal-title":"Anaesth Intensive Care"},{"key":"2025101109490480000_46.2.176.98","doi-asserted-by":"publisher","DOI":"10.1001\/jama.299.6.685"},{"key":"2025101109490480000_46.2.176.99","doi-asserted-by":"crossref","first-page":"324","DOI":"10.7196\/SAMJ.4556","article-title":"Errors in drug administration by anaesthetists in public hospitals in the Free State","volume":"101","author":"Labuschagne","year":"2011","journal-title":"S Afr Med J"},{"key":"2025101109490480000_46.2.176.100","unstructured":"International Organization for Standardization . ISO 80369-1 2010: Small-bore connectors for liquids and gases in healthcare applications - Part 1: General requirements. Geneva, Switzerland. Available: https:\/\/www.iso.org\/standard\/45976.html [Accessed September 22, 2020]."},{"key":"2025101109490480000_46.2.176.101","unstructured":"International Organization for Standardization . ISO 80369-6:2016: Small bore connectors for liquids and gases in healthcare applications - Part 6: Connectors for neuraxial applications. Geneva, Switzerland. Available: https:\/\/www.iso.org\/standard\/50734.html [Accessed September 22, 2020]."},{"key":"2025101109490480000_46.2.176.102","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.bpa.2011.02.009","article-title":"The contribution of labelling to safe medication administration in anaesthetic practice","volume":"25","author":"Merry","year":"2011","journal-title":"Best Pract Res Clin Anaesthesiol"},{"key":"2025101109490480000_46.2.176.103","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.161.19.2317"}],"container-title":["Regional Anesthesia &amp; Pain Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/rapm-2020-101836","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T16:49:25Z","timestamp":1760201365000},"score":1,"resource":{"primary":{"URL":"https:\/\/rapm.bmj.com\/lookup\/doi\/10.1136\/rapm-2020-101836"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,11,3]]},"references-count":103,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2021,1,19]]},"published-print":{"date-parts":[[2021,2]]}},"alternative-id":["10.1136\/rapm-2020-101836"],"URL":"https:\/\/doi.org\/10.1136\/rapm-2020-101836","relation":{},"ISSN":["1098-7339","1532-8651"],"issn-type":[{"value":"1098-7339","type":"print"},{"value":"1532-8651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,11,3]]}}}