February 2006, Volume 36 Number 2 , p 18 - 18
COHEN, MICHAEL R. RPh, MS, ScD
President of the Institute for Safe Medication Practices
Researchers studying perinatal drug errors learned of many pregnant women who were harmed or almost harmed when they received I.V. magnesium sulfate. Here are two examples:
* A woman in preterm labor received an infusion of magnesium sulfate administered through tubing connected to her I.V. line at a Y site. The tubing remained connected after the infusion was discontinued. After the woman delivered, tubing for an oxytocin solution was connected to the other Y-site connector. Instead of starting the oxytocin infusion as prescribed, a nurse accidentally restarted the magnesium sulfate. Later, the patient was found unresponsive and remains in a persistent vegetative state. * After preparing a bag of magnesium sulfate solution (intended to contain 40 grams/liter), a nurse started an infusion at 200 ml/hour to deliver a 4-gram bolus dose over 30 minutes. She monitored the patient for 20 minutes, then was called ...