THEME: CONCLUSION Institute for Safe Medication Practices Canada A KEY PARTNER IN oxytocin in the IV infusion solution is usually patients with increased risk of hemorrhage. A IV ADMINISTRATION-ASSOCIATED ERRORS expressed in milliunits per millilitre or units per litre REPORT MEDICATION INCIDENTS medical resident was unaware of the protocol Online: www.ismp-canada.org/err_index.htm (units/L). The administration rate for the solution is and instead ordered carbetocin (an oxytocin Oxytocin is commonly used to assist with labour and Phone: 1-866-544-7672 SUBTHEME: typically described using the amount of drug to be analogue) for a high-risk patient. The patient delivery, as well as to prevent and treat postpartum Errors in infusion pump connections or IV line delivered (e.g., milliunits/minute) or the volume of experienced significant bleeding. bleeding. Errors with this high-alert medication can set-up solution to be infused (e.g., mL/hour). cause considerable harm to the mother and the fetus. SUBTHEME: This multi-incident analysis has highlighted the need Improper connection of IV lines to the infusion pump Incident Example Incomplete hand-offs at transitions of care to ensure appropriate labelling of all oxytocin and/or the patient resulted in incorrect medication, products, preparations, and delivery systems; to As a result of confusion between units of Volume 19 • Issue 8 • October 23, 2019 incorrect dose, and dose omission errors. The lack of clear documentation at transitions of care standardize how doses, concentrations, and rates are measure, an infusion pump was programmed to Contributing factors included the need for multiple was a key contributor to oxytocin incidents. expressed; and to support clear documentation and deliver 3 times the intended dose of oxytocin. IV lines, a fast-paced work environment, heavy Reporters attributed poor documentation to heavy communication with the patient and those within workload, inexperienced staff, and distractions. workload, a fast-paced environment, inexperience, their circle of care. Ideally, the provision of oxytocin Errors Associated with Oxytocin Use: A Multi-Incident Analysis In its recent publication of best practices and involvement of many individuals in the patient’s in standardized, ready-to-use formats would optimize recommendations, Ontario’s Provincial Council for Incident Example circle of care. the safe use of this product. Maternal and Child Health (PCMCH) encourages During augmentation of labour, oxytocin was to standardizing oxytocin infusion rates and provides Oxytocin and its analogues are commonly adminis- which left 99 and 45 incident reports from the ISMP Incident Example ACKNOWLEDGEMENTS tered for induction and augmentation of labour.1-3 In Canada and NSIR databases, respectively, for be administered using a controlled-rate infusion tools, such as a sample order set, to reduce variation Oxytocin is clear and colourless, so IV infusion bags Ideally, oxytocin for infusion would be provided in a pump, while Ringer’s lactate was to run freely, in hospital practices across the province.10 Administration of oxytocin was put on hold addition to this indication, oxytocin is widely used to analysis. ISMP Canada gratefully acknowledges expert review 2-4 and syringes containing the medication are ready-to-administer format. The availability of such a intravenously, via gravity. During the set-up Communicating the rate in terms of both the amount when staff noted a deceleration in the fetal heart prevent and treat postpartum bleeding. However, of this bulletin by the following individuals (in indistinguishable from bags containing plain IV format would avoid the need for drug manipulation at process, the lines were mixed up, and the of drug (milliunits/minute) and the volume rate. The physician examined the patient and oxytocin can cause hyperstimulation of the uterus, Maternal, fetal, or neonatal harm was reported in alphabetical order): Hala Basheer RPh, PharmD, solution (i.e., bags of IV solution with nothing added) the bedside and would take advantage of robust oxytocin solution was inadvertently left to run (millilitres/hour) to be infused provides more clarity gave a verbal order to restart the oxytocin which in turn can result in fetal distress, the need for 12% of the reports to ISMP Canada and 29% of the MSc Infectious Diseases, Manager, Pharmacy or syringes containing other clear, colourless verification processes. However, sterile compounding freely without a pump. As a result, the patient and less opportunity for misinterpretation. infusion, but at a lower rate. A few minutes later, emergency caesarean section, or uterine rupture. A reports to NSIR. Most of the reported incidents in Services & Infection Prevention and Control, Joseph medications.6 Therefore, it is critical to ensure facilities (whether industry or hospital pharmacy- received a larger-than-intended dose of oxytocin, Standardized expression of doses and rates, together a second physician, who was taking over from multi-incident analysis was conducted to identify both data sets occurred during the drug Brant Hospital, Burlington, ON; Vanessa Paquette legible, complete, and accurate labelling of any based) face several challenges, such as the need for an error that led to the need for caesarean with the use of smart pumps (with drug libraries and the first, gave an order to restart the oxytocin at opportunities to improve patient safety with this administration step of the medication-use process. BSc(Pharm), PharmD, Clinical Pharmacy Specialist, 5 solution or device containing oxytocin. The analysis stability and sterility data specific to the formulations section. dose-error reduction software), can reduce the risk of the original dose. The two medication orders high-alert medication. Children's and Women's Health Center of BC; highlighted cases in which incomplete or omitted being produced and the need for resources to meet errors.10,11 were directly contradictory. The lack of written QUALITATIVE ANALYSIS P. Gareth Seaward MD FRCSC, Maternal Fetal labels led to patient safety issues. These labelling the demand for the high volumes of oxytocin used Independent double checks can be used to verify documentation regarding the decision to lower METHODOLOGY Medicine Specialist and QI Lead, PCMCH, Toronto, problems were typically due to interruptions, in practice. pump programming and the set-up of IV lines. Use of THEME: the rate of infusion was considered to be a factor The analysis revealed 3 main themes, each with ON; Laura Zahreddine RN, BScN, MN, Senior distractions, or competing priorities on the patient smart infusion pumps equipped with dose-error COMMUNICATION AND DOCUMENTATION GAPS in this incident. Reports of medication incidents associated with multiple subthemes (see Figure 1). Program Manager, Provincial Council for Maternal oxytocin were extracted from voluntary reports* care unit. SUBTHEME: reduction software can also aid in the safe 7 and Child Health, Toronto, ON. submitted to 3 ISMP Canada reporting databases THEME: Lack of appropriate safe storage measures administration of oxytocin. A standardized safety Communication and documentation gaps have been Use of standardized documentation tools and (Individual Practitioner Reporting, Community PREPARATION AND STORAGE CHALLENGES Incident Example checklist for oxytocin to be completed prior to identified as common themes in Canadian maternal/ communication strategies at care transitions is In some patient care areas, oxytocin is not subject to administration could be an additional safeguard.8 The newborn-related insurance claims.11 Similar issues recommended to promote clear, timely, and efficient Pharmacy Incident Reporting, and Consumer An unlabelled bag of what was presumed to be the same strict inventory control measures that are set-up of IV infusion lines should facilitate accurate were captured in the current analysis. exchange of patient information.13 Reporting) and the National System for Incident SUBTHEME: plain IV solution was retrieved, and an applied to other high-alert medications. Inappropriate and timely identification and tracing among the drug, Reporting (NSIR)† for the period from database Product preparation and/or labelling problems unspecified amount of the solution was access to oxytocin was described in more than the pump, and the patient. Consideration should be SUBTHEME: Patients have a vital role in supporting the safe use of inception to April 4, 2019. Key words used in the administered to a patient. Staff later noted 20 reports; for example, oxytocin ampoules were given to labelling primary IV tubing with the name of Absence of or deviation from protocol oxytocin. ISMP Canada is partnering with search were “oxytocin”, “pitocin”, and “syntocinon”. Nurses typically prepare oxytocin infusion solutions maternal cramping and fetal heart rate found in patient care areas by non-patient care staff the infusate, just above the injection port closest to stakeholders to develop an oxytocin-specific version on the patient care unit, just before use, by deceleration. An investigation revealed that the QUANTITATIVE FINDINGS withdrawing the medication from an ampoule or vial (e.g., housekeeping personnel). In these cases, the the patient and near the infusion pump (i.e., on the IV A lack of awareness of or compliance with hospital of the “5 Questions to Ask About Your Medications” bag contained oxytocin. The patient required 9 and adding the desired volume to a bag of medication had been left unsecured in the