Medication errors and mitigation strategies in obstetric anesthesia.

Abstract

Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm. Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anesthesia. In obstetric anesthesia, medication errors can include wrong medication, dose, route, time, patient, or infusion setting. These errors are often underreported, have the potential to be catastrophic, and most can be prevented. Implementation of various types of best practice cost effective mitigation strategies include recommendations to improve drug labeling, optimize storage, determine correct medication prior to administration, use non-Luer epidural and intravenous connection ports, follow patient monitoring guidelines, use smart pumps and protocols for all infusions, disseminate medication safety educational material, and optimize staffing models. Vigilance in patient care and implementation of improved patient safety measures are urgently needed to decrease harm to mothers and newborns worldwide.