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Simpson, Kathleen Rice PhD, RNC, FAAN; Knox, G. Eric MD

MCN, The American Journal of Maternal/Child Nursing: January-February 2009 - Volume 34 - Issue 1 - p 8–15
doi: 10.1097/
Original Article

Patient injury from drug therapy is the single most common type of adverse event that occurs in the in-patient setting. When medication errors result in patient injury, there are significant costs to the patient, healthcare providers, and institution. Some medications that have a heightened risk of causing significant patient harm when they are used in error are called “high-alert medications.”In 2007, the Institute for Safe Medication Practices added intravenous (IV) oxytocin to their list of high-alert medications. This is significant for perinatal care providers because oxytocin is a drug that they use quite freguently. Errors that involve IV oxytocin administration for labor induction or augmentation are most commonly dose related and often involve lack of timely recognition and appropriate treatment of excessive uterine activity (tachysystole). Other types of oxytocin errors involve mistaken administration of IV fluids with oxytocin for IV fluid resuscitation during nonreassuring (abnormal or indeterminate) fetal heart rate patterns and/or maternal hypotension and inappropriate elective administration of oxytocin to women who are less than 39 completed weeks' gestation. Oxytocin medication errors and subsequent patient harm are generally preventable. The perinatal team can develop strategies to minimize risk of maternal-fetal injuries related to oxytocin administration consistent with safe care practices used with other high-alert medications.

The medication given so often by perinatal nurses is examined here, in a whole new light.

Kathleen Rice Simpson is a Perinatal Clinical Nurse Specialist, St. John's Mercy Medical Center, St. Louis, MO, and an Editorial Board Member of MCN. Dr. Simpson can be reached via e-mail at

G. Eric Knox is a Professor, Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN.

The authors of this article have disclosed no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

© 2009 Lippincott Williams & Wilkins, Inc.