Safety of Oxytocin for Labour Induction/Augmentation

The Institute for Safe Medication Practices Canada (ISMP Canada) has identified oxytocin when used for labour induction or augmentation as a high alert medication that “bears a heightened risk of causing significant patient harm if used in error.” In October 2019, ISMP Canada published the results of its Errors Associated with Oxytocin Use: A Multi-Incident Analysis. The article reviews themes and subthemes in the 99 included incidents and provides case study examples of oxytocin incidents. The main themes and subthemes identified were:

  1. Preparation and storage challenges including product preparation and/or labeling problems and a lack of appropriate safe storage measures.
  2. IV administration-associated errors including errors in infusion pump connections or IV line set-up and infusion rate confusion
  3. Communications and documentation gaps including absence or deviation from protocol and incomplete hand-offs at transitions of care  

These themes provide an opportunity for all maternity health-care providers to review their practice and look for systemic ways to minimize errors.