Accidental Intra-Articular Atracurium Injection After Knee Arthroscopy: A Report of Medical Error Publisher



Irani PT ; Mortazavi SMJ ; Ayati Firoozabadi MA
Source: Archives of Bone and Joint Surgery Published:2025

Abstract

We presented the case of a patient who experienced a loss of responsiveness shortly after the tourniquet was deflated following knee arthroscopy. Incorrect intra-articular drug administration was suspected, and upon investigation, a used ampule of atracuri um, instead of tranexamic acid, was found in the safety box. The patient was promptly treated with neostigmine and received supportive respiratory care, resulting in the reversal of symptoms, full recovery, and discharge after two days. Adhering to the six rules of drug administration is essential to prevent patient harm due to incorrect drug administration. We recommend placing warning notes in each operating room to raise awareness of potential drug mix-ups due to their similar appearances. Furthermore, during intra-articular injections, the technician needs to verify the medication with the surgeon before administering the injection. Level of evidence: IV © 2025 Elsevier B.V., All rights reserved.