Anesthesiology Organizations Express Concern for Patients Harmed, Reaffirm Safety of Spinal Anesthesia

CHICAGO– In response to reported medication errors that harmed patients in Nashville, the Society for Obstetric Anesthesia and Perinatology (SOAP), the Anesthesia Patient Safety Foundation (APSF) and the American Society of Anesthesiologists (ASA)today reaffirmed that spinal anesthesia remains a safe and essential anesthetic technique when administered with appropriate medication. These devastating events must be seriously addressed, without calling into question the safety of this well-established form of care. SOAP, APSF and ASA extend their deepest concern and compassion to the patients and families who suffered harm in these events and encourage swift and thorough evaluation of the events and processes that contributed to these tragedies.

Spinal and epidural anesthesia are safe, well-established, and commonly used techniques that provide important benefit for millions of patients during childbirth, having surgery or other procedures. Although the circumstances of these events reportedly remain under investigation, serious events such as these reinforce the importance of rigorous investigation, transparency, and learning. A medication error involving neuraxial administration is distinct from an inherent complication of spinal or epidural anesthesia.

SOAP, APSF and ASA have previously highlighted the risks of wrong-drug and wrong-route medication errors and the importance of systems designed to prevent them. These include standardized and clearly labeled medications, separation of high-alert medications from those intended for neuraxial use, technology-assisted verification where available, and safeguards throughout pharmacy preparation, dispensing, and administration.

Analogous to the federal Aviation Safety Reporting System, SOAP, APSF and ASA’s Anesthesia Quality Institute are dedicated to patient safety through qualitative registries capturing data on events and providing a platform to learn from and prevent future errors.

Related resources

• APSF: Unraveling a Recurrent Wrong Drug–Wrong Route Error: Tranexamic Acid in Place of Bupivacaine
• APSF/ISMP: Preventing Wrong Drug–Wrong Route Errors Involving Tranexamic Acid and Local Anesthetics
• APSF: Medication Administration in Anesthesia
• SOAP: Information About Labor Epidurals: Your Questions Answered
• AQI: Anesthesia Incident Reporting System
• ASA: Statement on Standard Practice for Avoidance of Medication Errors in Neuraxial Anesthesia
• ASA: Statement on Neuraxial Analgesia or Anesthesia in Obstetrics
• ASA: Statement on Administration of Medications

About the Society for Obstetric Anesthesia and Perinatology
Society for Obstetric Anesthesia and Perinatology (SOAP) is a 501(c)(6) organization whose mission is to advance and advocate for the health of pregnant women and their babies through research, education, and best practices in obstetric anesthesia care. With over 2,500 global members, our vision is safe and equitable care for women and newborns everywhere.

About the Anesthesia Patient Safety Foundation
Anesthesia Patient Safety Foundation (APSF) is a 501(c)(3) charitable organization whose mission is to improve the safety of patients during anesthesia care by: 1) Identifying safety initiatives and creating recommendations to implement directly and with partner organizations 2) Being a leading voice for anesthesia patient safety worldwide 3) Supporting and advancing anesthesia patient safety culture, knowledge, and learning. APSF is a foundation of the American Society of Anesthesiologists (ASA).  

About the American Society of Anesthesiologists
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 60,000 members organized to advance the medical practice of anesthesiology and secure its future. ASA is committed to ensuring anesthesiologists evaluate and supervise the medical care of all patients before, during and after surgery. ASA members also lead the care of critically ill patients in intensive care units and treat pain in both acute and chronic settings. The Anesthesia Quality Institute, a foundation of the ASA, is a Patient Safety Organization (PSO) and home to NACOR, the largest anesthesia registry in the world. NACOR is also a Qualified Registry (QR) and Qualified Clinical Data Registry (QCDR).