Medication and dosing errors around birth

What is it?

Medication errors take several forms. The wrong drug. The right drug at the wrong dose. The right drug given at the wrong time, or not given at all. The right drug given by the wrong route.

Around birth, some categories come up repeatedly.

oxytocin. It makes the uterus contract. Too much produces tachysystole, meaning more than five contractions in 10 minutes averaged over 30 minutes. That shortens the gaps in which the baby recovers oxygen. ¹

Magnesium sulphate. Used to prevent seizures in preeclampsia, and separately before 32 weeks to protect the baby's brain. The two uses have different dosing and monitoring. ^{4 7}

Antibiotics in labor. Given to prevent Group B strep infection in the baby. Timing before delivery matters. ⁵

Anesthetic medicines. Given near the spinal nerves or into the bloodstream, with effects on blood pressure that reach the baby through the placenta. ⁸

Newborn medicines. Almost all are dosed per kilogram. A baby weighing 1.2 kg and a baby weighing 4 kg need very different amounts of the same drug. This is where decimal errors do the most harm. ³

Resuscitation medicines. Epinephrine and volume are given during newborn resuscitation, with doses and routes set out in the algorithm. ⁹

What does standard care look like?

Weight-based dosing for newborns, with the weight recorded and the calculation documented. ³

Independent double-checking of high-risk medicines, which most units require.

Infusions on a controlled pump, with the rate recorded and every change timed. ¹

Monitoring appropriate to the drug. For oxytocin, contraction frequency and the fetal heart rate. For magnesium, reflexes, breathing rate and urine output. ⁴

Stopping or reducing oxytocin as a first-line response to a concerning tracing. ¹⁰

Antibiotics given at the right time in labor. ⁵

Resuscitation medicines given per the algorithm, with doses and routes as specified. ⁹

Every dose recorded with the drug, dose, route and time.

What can go wrong?

A decimal error in a newborn dose. This is the classic high-harm error in neonatal care, because doses are small and weight-based. ³

oxytocin increased into tachysystole, or continued through a concerning tracing. ^{1 10}

Magnesium given at the wrong dose, or monitoring not done, or the two indications confused. ⁴

Antibiotics in labor not given, or given too late. ⁵

A medicine given to the wrong patient, which in a busy unit with several laboring patients is a recognized risk.

The wrong route, including a drug intended for one route given by another.

A known allergy not checked. ⁵

Resuscitation medicines given at the wrong dose or by the wrong route. ⁹

Glucose management errors in a sick newborn, where both low and high blood sugar worsen brain injury. ⁶

Whether any of this amounts to a departure from the standard takes a physician expert reading the whole record.

Which injuries can follow?

The injury depends entirely on the medicine involved.

• HIE, where excessive oxytocin reduced oxygen delivery and was not corrected. ¹¹
• Neonatal seizures, from several routes including glucose and electrolyte errors. ¹²
• Low blood sugar and brain injury. ⁶
• Neonatal sepsis, where antibiotics in labor were missed or late. ⁵
• Kernicterus, where treatment for jaundice was delayed. ¹³
• Hearing loss, from certain antibiotics given at high doses or for long periods. ¹⁴
• For the mother, effects of magnesium overdose, and anesthesia complications. ⁴

What does this look like in the records?

Request the medication administration record by name. It is the list of every drug given, with dose, route and time.

Also request

• The infusion records for oxytocin and magnesium, showing every rate change with its time. ¹
• The anesthesia record, which is usually filed separately and has timed entries throughout. ⁸
• The newborn resuscitation record, including any medicines given. ⁹
• The NICU medication record, including the weight used for dosing. ³
• Nursing notes around the time of any concern.
• Any incident report, which may or may not be part of the record set you are entitled to. Ask, and ask in writing. ^{2 15}

What to compare

• The oxytocin rate against the contraction pattern on the fetal monitoring strip. ¹
• The time of the first antibiotic dose against the time of delivery. ⁵
• The recorded weight against the doses calculated from it. ³

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.