Medication errors in labor and delivery: reducing maternal and fetal harm
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Pennsylvania. Patient Safety Authority. ECRI (Organization) Institute for Safe Medication Practices.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2009
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Labor, Obstetric -- drug effects Medication Errors -- adverse effects Medication Errors -- prevention & control Risk Management -- methods Disclosure Fetus -- drug effects Maternal Welfare Perinatal Care -- methods Pregnancy Prenatal Care -- methods Female Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Practitioners who work in labor and delivery units may administer an assortment of high-alert medications during the birthing process. These medications, such as oxytocin (used to induce and augment labor) and magnesium sulfate (used to treat preeclampsia and to delay preterm birth), are often administered intravenously. Medications used to manage pain, such as morphine and HYDROmorphone, may also be administered intravenously, while others, such as bupivacaine and fentanyl, may be administered via the epidural route. When high-alert medications are used in error in labor and delivery units, the event can affect both the mother and the fetus. Between June 2004 and April 2009, Pennsylvania healthcare facilities submitted 2,611 event reports involving medication errors in labor and delivery units. Analysis reveals that the most common medication error event type associated with this area is dose omission (22.5%), followed by wrong drug (10.7%). Further analysis showed that 46.4% of wrong-dose/overdosage errors and 55.2% of wrong-rate errors involved high-alert medications. Strategies to prevent medication errors and patient harm in this specialty setting include standardizing the dosing and administration protocols as well as standardizing the concentrations and dosing units of drug infusions and adopting a policy that all infusions be administered with an infusion pump.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- NLM Unique ID:
- 101561955 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101561955