Accidental oral administration of Monsel’s solution during caesarean delivery

Published:September 01, 2022DOI:
      Wrong route medication error via the intravenous (IV) or neuraxial route has been reported in obstetric anaesthesia.
      • Yentis S.M.
      • Randall K.
      Drug errors in obstetric anaesthesia: a national survey.
      Anaesthetists infrequently administer oral medication in the theatre environment. We report an unusual medication error of accidental oral administration of Monsel’s solution prior to caesarean delivery (CD).
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        • Yentis S.M.
        • Randall K.
        Drug errors in obstetric anaesthesia: a national survey.
        Int J Obstet Anesth. 2003; 12: 246-249
        • Miller D.T.
        • Roque D.M.
        • Santin A.D.
        Use of Monsel’s solution to treat obstetrical haemorrhage: a review and comparison to other topical agents.
        Am J Obstet Gynecol. 2015; 212: 725-735
        • Diller T.
        • Helmrich G.
        • Dunning S.
        • et al.
        The human factors analysis classification system (HFACS) applied to health care.
        Am J Med Qual. 2013; 29: 181-190
        • Bryan R.
        • Aronson J.K.
        • Williams A.
        • Jordan S.
        The problem of look-alike, sound-alike name errors: Drivers and solutions.
        Br J Clin Pharmacol. 2021; 87: 386-394
        • Wahr J.A.
        • Abernathy J.H.
        • Lazarra E.H.
        • et al.
        Medication safety in the operating room: literature and expert-based recommendations.
        Br J Anaesth. 2017; 118: 32-43
        • Orser B.A.
        • David U.
        • Cohen M.R.
        Perioperative medication errors: building safer systems.
        Anesthesiology. 2016; 124: 1-3
        • Gui J.L.
        • Nemergut E.C.
        • Forkin K.T.
        Distraction in the operating room: A narrative review of environmental and self-initiated distractions and their effect on anesthesia providers.
        J Clin Anesth. 2021; 68: 110110
        • Sheridan H.
        • Plaza E.
        • Hendren G.
        • Hu J.
        • Ortman A.J.
        Noise levels during caesarean delivery: a prospective observational study.
        Int J Obstet Anesth. 2021; 48: 103211
        • Grigg E.B.
        • Roesler A.
        Anesthesia medication handling needs a new vision.
        Anesth Analg. 2018; 126: 346-350
      1. The Royal College of Anaesthetists. Safe drug management in anaesthetic practice 2020. Accessed January 15, 2022.