Abstract :Objective: Draw attention for risk factors of drug error fatal mistakes that jeopardize patient life.
Case Presentation: In this study we presented a fatal drug error, intrathecal injection of tranexamic acid before caesarean section which leaded to neurotoxicity and repeated seizures, complicated by ventricular fibrillation and maternal mortality.
Conclusion: We should emphasize true drug for true patient by right method of administration especially in drugs that can easily endanger patient safety, legal rules should play a role to avoid repeated mistakes.