Inadvertent spinal injection of ondansetron

Cesarean sections under spinal anesthesia are now a daily occurrence in most tertiary hospitals. We report the first published case of inadvertent spinal injection of ondansetron without any neurological sequelae in a patient undergoing elective Cesarean section under spinal anesthesia. She did not experience any permanent neurological sequelae, and also did not exhibit any central neuraxial opioid side effects—nausea, vomiting or pruritus. Vigilance is essential to reduce the risk of wrong route delivery of drugs, especially when presented in very similar-looking 2 mL ampules as in our institution.