Responsiveness to the chlorhexidine epidural tragedy: a mental block?

Paralysis following an epidural anaesthetic is a rare event. The mechanism usually involves accidental injection of skin antiseptic instead of local anaesthetic. Two recent cases, one involving paralysis, the other a "near-miss", are described. The first case resulted in an extensive root cause analysis and an admission of liability by the hospital. The response of the anaesthetic community and the New South Wales Department of Health was swift but failed to produce uniform protocols across the region. Furthermore, the requirement of medical staff to double check medications with a second person before their administration was not addressed. Abandoning a more effective but neurotoxic antiseptic solution in favour of a solution with weaker antiseptic properties, as had previously occurred in one Sydney hospital, could incur higher risks of epidural infection. Defensive medical practice can lead to unwanted negative consequences.