Prescribing Errors Associated With Use of Oxytocin and Strategies to Mitigate Risk of Such Errors: Part I

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

Intravenous (IV) oxytocin is indicated for the induction or stimulation of labor, control of postpartum uterine bleeding, and adjunctive treatment of abortion. However, improper administration of oxytocin can cause hyperstimulation of the uterus, which in turn can result in fetal distress, the need for an emergency cesarean section, or uterine rupture. Sadly, a few maternal, fetal, and neonatal deaths have been reported.

In February 2020, the Institute for Safe Medication Practices (ISMP) analyzed reports associated with oxytocin submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP) between 1999 and 2019. Previously, in October 2019, ISMP Canada published a multi-incident analysis in which a total of 144 reports of oxytocin-related incidents submitted to ISMP Canada and the Canadian National System for Incident Reporting (NSIR) between 2000 and 2019 were analyzed.¹ Analysis of the reports are from both ISMP and ISMP Canada.

We will first start off with examples of prescribing errors in this series along with related safe practice recommendations.

• Oxytocin errors related to prescribing were associated with selecting the wrong drug from a computerized prescriber order entry (CPOE) screen when searching using only 3 letters, “PIT,” “OXY,” or “OXY10.” Multiple errors have been reported due to selection of the wrong drug on entry systems.
• Two errors were reported in which physicians had entered “PIT” for Pitocin (the brand name for oxytocin) in the CPOE system but accidentally selected Pitressin (the discontinued brand name for vasopressin still found in some CPOE systems).
• A physician who intended to prescribe OxyCONTIN (brand name for oxyCODONE) 10 mg every 12 hours as needed for pain for a postpartum patient entered “OXY10” into the CPOE search field, but inadvertently selected “oxytocin 10 units IV” every 12 hours as needed for pain. The nurse questioned the pharmacist regarding the order, but by the time the pharmacist followed up with the prescriber and corrected the error, the patient had received one dose of IV oxytocin.   

ISMP recommends requiring a minimum of 5 letters when searching for a drug name in electronic systems, resulting in ideally only one drug name appearing in the results field. Adding an indication when prescribing could also support the correct selection and appropriate use of medications. In addition, remove outdated brand names, including Pitressin, from CPOE systems, and avoid using abbreviations such as “PIT” for either Pitocin or Pitressin or “OXY” for oxytocin or oxyCODONE/OxyCONTIN. The use of carefully designed, reviewed, and maintained standard order sets, such as those for prescribing oxytocin antepartum and/or postpartum, can also reduce drug selection errors during prescribing.

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.