Inadvertent administration of dual antiplatelet therapy to a patient with an indwelling epidural catheter

Summary We describe the case of a middle‐aged patient who suffered a non‐ST elevation myocardial infarction (NSTEMI) on day 1 postoperatively following an elective abdominal aortic aneurysm (AAA) repair. The NSTEMI was managed with dual antiplatelet therapy; unfortunately this was initiated without due consideration to the fact he had an epidural in situ. Once this clinical conflict was identified, careful decisions were taken regarding concurrent management of his NSTEMI and epidural, particularly regarding timing of catheter removal. The patient suffered no neurological sequelae. The case raises two clear learning points. Firstly, it highlights the logistical and ethical difficulties of managing serious medical conditions when treatments expose patients to significant harm. Secondly, it emphasises the contribution of human factors to medical errors in anaesthesia and intensive care. As a result of this case, we developed bedside epidural alert notices in our institution to reduce the risk of similar incidents occurring in the future.