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REVIEW ARTICLE
Year : 2022 | Volume
: 12
| Issue : 2 | Page : 94-98
Medication errors in a parturient: A huge cost to two lives
Manpreet Kaur, Bharat Yalla, Anjan Trikha
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
Correspondence Address:
Prof. Anjan Trikha
5th Floor Teaching Block, Department of Anaesthesiology, AIIMS, New Delhi - 110 029
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/JOACC.JOACC_17_22
Medication errors in a parturient can be devastating as two lives are involved. Owing to the absence of critical incident reporting in parurients in multiple countries of the world, these errors are underreported. We herein discuss the common medication errors in a parturient, the published literature, and the management protocols practiced.
Keywords: Drug errors, medication errors, parturients
The ultimate goal of managing a parturient is the safe delivery of both the mother and her unborn fetus which can be hampered by medication errors. There is vast literature on medication errors in non-pregnant women, but there is comparatively less literature on parturients who have unique physiological changes and specific medications used in maternity units.[1],[2],[3],[4],[5],[6] Owing to the absence of critical incident reporting in multiple countries of the world, these errors are underreported and whatever published literature is available only represents the tip of the iceberg. It becomes even more important in parturients where two lives are at stake. In addition, obstetric patients are more socially important and more likely to litigate because pregnancy is a normal physiological state and errors in a parturient can cost two lives.
Commonly used medications in maternity units for parturients include local anesthetics, antibiotics, oxytocin, methergine, magnesium sulfate, tranexamic acid, ephedrine, phenylephrine, and resuscitation drugs. Hence, medication errors were more likely to be related to these drugs. Systemic causes of medication errors are related to prescribing, preparation, administration, dispensing, and storage and treatment monitoring, with the first three most associated with maximum errors [Figure 1].[1] A plethora of medication errors include wrong drug administration, wrong routes, wrong doses, wrong time, wrong patients, patient monitoring errors, pump programming errors, erroneous infusion, dose-omission errors, and many more [Figure 2]. Different drugs used in obstetric patients have been reported to cause mishappenings because of medication errors and are summarized in [Table 1] and [Tablle 2]. Local anesthetics have been used in parturients for labor analgesia and transversus abdominus plane block (TAP block) for post-operative pain; however, if used in the wrong dosage or through the wrong route [intravenous (IV) instead of epidural], it can result in local anesthetic systemic toxicity (LAST).[7],[8],[9],[10],[11] Literature search reveals that oxytocin (for induction and augmentation of labor) and magnesium sulfate (for treating pre-eclampsia and delaying pre-term birth) top the list of intravenously administered drugs.[4],[12],[13],[14],[15],[16],[17],[18] Oxytocin has been used in wrong drug concentrations because of multiple errors such as infusion pump abnormalities, IV pump tubing mix-ups, and prescription errors (milligram vs microgram). Multiple reports of accidental spinal tranexamic acid (used extensively in post-partum hemorrhage) usage instead of bupivacaine (similarly looking ampules) has come up recently, which is associated with a high mortality rate of greater than 50% and permanent neurological sequel in survivors.[3],[19],[20],[21],[22] Epidural infusion prepared with IV antibiotics instead of opioids in error (ampule error, wrong route) has also been reported in the parturient.[23],[24] Administration of a maternal drug into newborn (wrong patient), for example, methylergonovine to newborn,[25],[26] has also been reported in the literature.
Table 1: Summary of the common medication errors, their monitoring strategies, and management protocols in parturients
Table 2: Literature on medication errors committed in obstetric patients and their managementThese drug errors in obstetrics are preventable. Multiple strategies are suggested for the reduction of the risk of medication errors in a parturient. It is a good idea to double-check WRONGS at multiple levels [Figure 2] such as wrong drugs, wrong concentrations, wrong rates, wrong patients, wrong time, wrong pump settings, line attachments, and patients before administering high-alert medications, such as magnesium sulfate, oxytocin, and epidural medications. Wrong drug problems can be reduced by barcode scanning of drug containers in resource-rich hospitals but might not be feasible in low resource settings. However, the use of a simple color coding system, labeling all the drugs, or crosschecking the labeled drug by a second person can be used for the prevention of wrong drug administration.[27] Standardized concentrations and dosing regimens with bold labels should be adopted for commonly used medications such as oxytocin and magnesium sulfate, and all the staff should be trained and directed regularly for these standard concentrations. Similarly looking drugs such as EPINEPHrine and ePHEDrine, tranexamic acid, and bupivacaine should not be kept side by side in anesthesia or epidural cart. Unrecognized rate errors eventually lead to drug dosage errors, so infusion pumps should be checked for any decibel errors which can result in large changes in drug dosages. Different types of pumps should be used for IV and epidural infusions. Epidural infusions should not have a side infusing port, labeled in bold “For Epidural Use Only,” and any infusion which is discontinued should be immediately removed, thereby reducing such errors to a large extent. Potential errors of the wrong patient can be reduced by separating newborn medications from those used for mothers in perinatal areas.[2],[6]
Parturients should be frequently monitored for vital signs, oxygenation, levels of consciousness of the laboring patients, and fetal heart rate monitoring. The most common medication errors in obstetric patients are summarized in [Table 1]. Each drug bolus should be followed by extensive monitoring. However, in an under-developed country, under-staffed shifts may result in potential monitoring errors. Such a problem can be overcome by incorporation of regular medication safety staff training for efficient monitoring of tell-tale signs,[2] inculcating checklists into the system, increasing staffing during the nightshifts for reducing human stress errors, and increasing access to a supportive resource.[1],[2],[6],[12] Situational awareness and vigilance are essential during the management of a parturient and can aid in the reduction of human factors.
For the reduction of medication errors, there is the formulation of multiple regulatory authorities internationally, such as the National Coordinating Council for Medication Error Reporting and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP).[4],[12] Medication errors reported to national health care supervisory can serve as a useful platform for learning from the commonly performed medication errors. However, there is no specific health care supervisory or critical incident reporting systems in India for medication errors committed in a parturient.
To conclude, medication errors in a parturient can be devastating as two lives are involved and meticulous steps should be undertaken to prevent them. Hence, vigilance at each step of drug administration from prescription to preparation to administration and intensive monitoring after any drug administration can prevent catastrophes.
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References
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