Pharmacy Management/Distribution and Communication Errors Associated With Use of Oxytocin and Strategies to Mitigate Risk of Such Errors: Part III

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

This blog is a continuation of our three-part series regarding errors that have been extracted from ISMP Canada¹ and ISMP analysis of oxytocin incidents. Part I covered prescribing errors and part II explained administration errors. Related safe practice recommendations were also discussed in both parts.

In part III we discuss errors associated with pharmacy management and distribution of oxytocin, communication errors, as well as risk mitigation strategies.

Key findings involved in pharmacy management/distribution errors include:

• 40% of all oxytocin-related reports submitted to ISMP described look-alike vials that led to, or could have led to, mix-ups between oxytocin and another product
• Many of the reported errors involved dispensing or stocking automated dispensing cabinets (ADCs) with the wrong product
• The most common, recent reports involved both generic (oxytocin) and brand (Pitocin) vials (10 units/mL) that looked like ondansetron vials (4 mg/2 mL) from various manufacturers. The risk of a mix-up between these products is heightened because they are often stored alphabetically near each other on pharmacy shelves and used for the same patient population, especially during cesarean sections. In some cases, a shortage of ondansetron was a factor requiring purchase of an available product from a different manufacturer in vials that looked like oxytocin/Pitocin vials.
• Reports of other medications packaged in vials that look similar to oxytocin/Pitocin within the past 5 years included clindamycin and metoclopramide.

Strategies would include conducting a proactive assessment to ensure that vials or bags used in the facility do not look similar to other medication vials or premixed infusions bags,. If similarities are noticed, and the drug/solution cannot be purchased from a different manufacturer/supplier, implement strategies (e.g., auxiliary labeling on vials, infusion bags, bins, ADC screens) to avoid confusion and warn all users about the risk. In addition, separate the storage of look-alike oxytocin and ondansetron vials (and other look-alike vials) in the pharmacy and patient care storage locations. As always, utilize barcode scanning to ensure that the right product has been selected.

Communication Errors

• The lack of clear communication and/or documentation during transitions of care was a key contributor to oxytocin incidents. Reporters attributed poor communication/documentation to heavy workload, a fast-paced environment, inexperience, and involvement of many individuals in the patient’s care.
• Administration of oxytocin was put on hold when staff noted a deceleration in the fetal heart rate. Fifteen minutes later, the physician examined the patient and gave a verbal order to restart the oxytocin infusion, but at a lower rate. A few minutes later, a second physician, who was taking over for the first, gave an order to restart the oxytocin at the original dose. The lack of documentation regarding the decision to lower the rate of infusion was considered to be a factor in this incident.
• Reported errors involved verbal orders or requests to the pharmacy for “Pitressin” (the discontinued brand name for vasopressin) that were misheard as Pitocin (brand name for oxytocin). Although Pitressin has been discontinued, vasopressin is sometimes still referred to as “PIT” or “Pitressin”. The few errors in which “Pitressin” infusions were dispensed instead of the intended Pitocin infusion resulted in harm (e.g., pulmonary edema).

ISMP recommends supporting clear communication/documentation. Use standardized communication strategies (e.g. SBAR) and documentation tools during transitions of care to promote clear, timely, efficient exchange of patient information. To avoid confusion between medications, limit verbal orders to emergencies or under sterile conditions. When they are needed, readback (or repeat back under sterile conditions) is a must. Engage patients and their families in the birth planning process and encourage them to ask questions. This level of communication can help prevent errors in various parts of the medication use process.

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.