[Accidental epidural administration of distilled water: systemic analysis of one case].

Four milliliters of distilled water was accidentally injected during labor epidural analgesia in a 32-year-old woman. This epidural injection resulted in severe and instantaneous thoracolumbar pain, which disappeared after epidural administration of NaCl 0.9% 5 mL followed by 20 ml of an analgesic mixture (ropivacaïne 0.1%+sufentanil 0.25 microg/ml). There was no evidence of any neurologic deficit or residual pain until discharge 10 days later. Although no other cases of accidental epidural injection of distilled water have been described up to now, a literature survey showed that it had been used previously as an old method to find the epidural space. However, few experimental data suggest that distilled water can be neurotoxic, which strictly contraindicates its use by epidural route. We used the Reason's systemic analysis model to identify each step that contributed to this error. Corrective measures were then implemented to avoid the recurrence of this error. Copyright (c) 2009 Elsevier Masson SAS. All rights reserved.