The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Accidental Intra-articular Atracurium Injection after Knee Arthroscopy: A Report of Medical Error

Document Type : CASE REPORT

Authors
Pouya Tabatabaei Irani
SM Javad Mortazavi
Mohammad Ayati Firoozabadi
Joint Reconstruction research center, Tehran University of medical science, Tehran, Iran
10.22038/abjs.2025.82120.3753
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 atracurium, 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
Keywords
Arthroscopy
Atracurium
Medical error
Subjects

  1.  

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The Archives of Bone and Joint Surgery
Volume 13, Issue 9
September 2025
Pages 600-602

  • Receive Date 09 September 2024
  • Revise Date 04 June 2025
  • Accept Date 16 June 2025