Administration Errors Associated With Use of Oxytocin and Strategies to Mitigate Risk of Such Errors: Part II

^{By: Neha Kumar, PharmD, 2019-2020 FDA/ISMP Safe Medication Management Fellow}

This blog is a continuation of our series regarding errors that have been extracted from ISMP Canada¹ and ISMP analysis of oxytocin incidents. In part I we discussed prescribing errors, along with related safe practice recommendations. In part II we discuss a variety of errors that were associated with administration of oxytocin as well as risk mitigation strategies.

Administration errors were associated with nursing admixture without complete labeling, infusion pump or intravenous (IV) line mix-ups, infusion bag swaps, infusion rate confusion and inadvertent bolus doses from leftover drug in tubing.

Examples of errors include:

• An unlabeled bag of what was presumed to be plain IV solution was later found out to be oxytocin. The patient who inadvertently received the oxytocin required an emergency cesarean section.
• During the set-up process, the patient’s IV Lactated Ringer’s line, which was to be administered rapidly via gravity, and their IV oxytocin line, which was to be administered in a controlled, prescribed rate via an infusion pump, were mixed up. As a result, the patient received a larger-than-intended dose of oxytocin and this led to the need for a caesarean section.
• A nurse quickly gathered what she thought was an oxytocin infusion but did not scan the bag’s barcode prior to hanging the infusion. An hour after starting the infusion, the mother experienced hypotension, weakness, and vomiting and was given a dose of IV ondansetron. Later, when the nurse was hanging a replacement bag of oxytocin, she noticed that the initial infusion bag contained magnesium (20 g/500 mL), not oxytocin (30 units/500 mL). The mother’s magnesium toxicity was treated with IV calcium gluconate with improvement in symptoms.
• Residual oxytocin left in an obstetrical patient’s IV line eventually led to fetal hypoxia when a Lactated Ringer’s hydrating solution was rapidly infused through the same IV line.

ISMP recommends that organization’s reduce access to unneeded medications and when possible and avoid bringing any medication to the patient’s bedside until it is prescribed and needed. This is a key-error reduction strategy, particularly in birthing units where emergent circumstances may require rapid changes in the plan of care. Additional strategies include:

• Providing patient care units with ready-to-use IV bags that are boldly labeled on both sides to avoid the need for drug manipulation at the bedside.
• If oxytocin infusions must be prepared on patient care units during an emergency, require an independent double check of the preparation and provide preprinted labels to affix to prepared bags.
• Employ barcode scanning technology prior to preparation, dispensing, stocking, and administration of oxytocin.
• Deliver all IV oxytocin via smart infusion pumps with an engaged dose error-reduction system. Bi-directional smart pump interoperability with the electronic health record will also reduce the risk of programming errors.
• Always communicate orders for oxytocin infusion in terms of dose rate (e.g., milliunits/minute), and align oxytocin dosing units and concentration with the smart pump dose error-reduction system.
• Label the IV tubing on oxytocin infusions just above the injection port closest to the patient and just above the pump.
• When setting up an infusion, trace the line from the infusion bag to the pump, and from the pump to the patient (and/or vice versa), to ensure the correct line attachment. Independent double checks can be used to verify the setup of IV lines.
• Promptly discard discontinued bags and change oxytocin tubing to ensure no residual drug is left behind in the tubing.

QUESTIONS:

For the more details please refer to the full article:

ISMP. Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. ISMP Acute Care Medication Safety Alert! 2020; 25(3):1-5. https://www.ismp.org/resources/errors-associated-oxytocin-use-multi-organization-analysis-ismp-and-ismp-canada

References:

ISMP Canada. Errors associated with oxytocin use: a multi-incident analysis. ISMP Canada Safety Bulletin. 2019;19(8):1-5.