Sequential drug verification errors resulting in wrong drug administration during caesarean section.

Area of Science:

• Obstetrics and Gynecology
• Clinical Pharmacy
• Patient Safety

Background:

• Medication errors pose significant risks in obstetric care.
• Accurate drug administration is critical during emergency procedures like cesarean sections.

Purpose of the Study:

• To analyze a specific medication error incident involving a parturient.
• To identify the root causes of a drug administration error during an emergency cesarean section.

Main Methods:

• Case report of an adverse drug event.
• Root cause analysis (RCA) of a medication administration error.
• Review of hospital pharmacy dispensing and clinical administration protocols.

Main Results:

• Phentolamine was mistakenly administered intravenously to a parturient instead of Syntocinon.
• Errors originated in the hospital pharmacy and were missed by subsequent checks.
• The final check before administration failed to prevent the wrong drug delivery.

Conclusions:

• The incident revealed a systemic failure in drug management and administration.
• There is a need to evaluate and implement robust measures to prevent drug administration errors in obstetric settings.