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 November 2013, ISMP Canada published the results of its Aggregate Analysis of Oxytocin Incidents voluntarily reported by health-care providers. The article reviews themes and subthemes in the 74 included incidents and provides case study examples of oxytocin incidents. The main themes and subthemes identified were:
- Mix-ups between manufacturer vials of different medications, including several drugs with similar packaging.
- Mix-ups between practitioner-prepared bags or syringes, such as programming the pump for oxytocin with another drug’s infusion rate or selection of the incorrect and unlabelled prepared syringe.
- Doses higher than intended, such as where there was no standardized protocol, confusion between units of measure, or administration without a pump.
- Doses lower than intended.
- Errors in route of delivery, especially between IV oxytocin and epidural analgesia.
- Infusion of oxytocin without a primary line.
These themes provide an opportunity for all maternity health-care providers to review their practice and look for systemic ways to minimize errors.