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
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Tabatabaei Irani, P. , Mortazavi, S. J. and Ayati Firoozabadi, M. (2025). Accidental Intra-articular Atracurium Injection after Knee Arthroscopy: A Report of Medical Error. The Archives of Bone and Joint Surgery, 13(9), 600-602. doi: 10.22038/abjs.2025.82120.3753
MLA
Tabatabaei Irani, P. , , Mortazavi, S. J. , and Ayati Firoozabadi, M. . "Accidental Intra-articular Atracurium Injection after Knee Arthroscopy: A Report of Medical Error", The Archives of Bone and Joint Surgery, 13, 9, 2025, 600-602. doi: 10.22038/abjs.2025.82120.3753
HARVARD
Tabatabaei Irani, P., Mortazavi, S. J., Ayati Firoozabadi, M. (2025). 'Accidental Intra-articular Atracurium Injection after Knee Arthroscopy: A Report of Medical Error', The Archives of Bone and Joint Surgery, 13(9), pp. 600-602. doi: 10.22038/abjs.2025.82120.3753
CHICAGO
P. Tabatabaei Irani , S. J. Mortazavi and M. Ayati Firoozabadi, "Accidental Intra-articular Atracurium Injection after Knee Arthroscopy: A Report of Medical Error," The Archives of Bone and Joint Surgery, 13 9 (2025): 600-602, doi: 10.22038/abjs.2025.82120.3753
VANCOUVER
Tabatabaei Irani, P., Mortazavi, S. J., Ayati Firoozabadi, M. Accidental Intra-articular Atracurium Injection after Knee Arthroscopy: A Report of Medical Error. The Archives of Bone and Joint Surgery, 2025; 13(9): 600-602. doi: 10.22038/abjs.2025.82120.3753
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