Hospital Pharmacy - June 2019 - 155

825730
research-article2019

HPXXXX10.1177/0018578719825730Hospital PharmacyCohen and Smetzer

ISMP Med Error Report Analysis

Mix-Ups Between Epidural Analgesia and
IV Antibiotics in Labor and Delivery Units
Continue to Cause Harm

Hospital Pharmacy
2019, Vol. 54(3) 155-159
© The Author(s) 2019
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https://doi.org/10.1177/0018578719825730
DOI: 10.1177/0018578719825730
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Michael R. Cohen1 and Judy L. Smetzer1
Within weeks of each other this past fall, 2 hospitals reported
mix-ups between epidural analgesia and intravenous (IV)
antibiotics in labor and delivery (L&D) units. These mix-ups
mimic previously published events and have similar contributing factors including look-alike infusion bags, overlooked
warning labels, and a point-of-care barcode medication
administration (BCMA) system that was not fully engaged.
However, unlike the prior events, drug shortages also played
a role in the most recent errors.

Recent Errors
Epidural FentaNYL With Bupivacaine
Administered IV
An obstetrician prescribed IV penicillin G 5 million units for
a woman in labor along with an order to "prepare the patient
for an epidural." Although the patient was experiencing few
contractions, the L&D nurse obtained infusion bags of IV
penicillin G and epidural fentaNYL (2 µg/mL) with bupivacaine (0.125%) from the automated dispensing cabinet
(ADC) and placed them in the patient's room on the counter,
with the pharmacy labels face down.
The pharmacy label was on the same side as the manufacturer's primary label. A red "Epidural Use Only" warning
label was on the front of the fentaNYL with bupivacaine bag,
but from the back, the bag looked nearly identical to the penicillin G bag. The epidural tubing was stored in the patient's
room, but it was not near the bag of fentaNYL with bupivacaine. Both infusions had been prepared by the pharmacy in
50-mL bags of 0.9% sodium chloride, although the penicillin
G bag contained a total of 50 mL, and the fentaNYL with
bupivacaine bag contained a total of 100 mL, so it looked a
bit overfilled.
Prior to the event, the pharmacy had been purchasing
larger 100-mL bags of epidural fentaNYL with bupivacaine
from an outsourcer, which had a bright yellow label.
However, due to the recent drug shortage of both bupivacaine and 100-mL bags of 0.9% sodium chloride, the pharmacy had been compounding the epidural solution using
bupivacaine vials taken from epidural and patient-controlled
analgesia kits. The bupivacaine and fentaNYL were mixed
in a 50-mL bag of 0.9% sodium chloride, and then additional
diluent was added to reach a total volume of 100 mL. The

pharmacy applied its standard white label to the fentaNYL
with bupivacaine bags, like other pharmacy-prepared infusions, along with a red epidural auxiliary warning label.
However, L&D nurses had not been informed about the
changes in bag size and label colors. So, at the time of the
event, they expected epidural infusions to be in 100-mL bags
with a yellow label.
The nurse picked up the wrong bag from the counter, not
realizing that she had fentaNYL with bupivacaine in hand
instead of the intended penicillin G. Although a BCMA system had been fully implemented in other areas, information
technology staff were still working with the L&D unit to
implement the technology in this last patient care unit. One
of the barriers to implementation had been the requirement
for pharmacy to verify all medication and solution orders
before the system was operational. However, epidural infusions were typically ordered and documented after anesthesia staff started the infusion.
Soon after receiving the wrong medication, the woman
began having seizures and experienced respiratory arrest. A
responding anesthesiologist noticed the error after reading
the label on the infusing IV bag and immediately administered IV naloxone and a bolus of lipid emulsion, with an IV
lipid emulsion infusion to follow. The baby was delivered via
emergency cesarean section and had a low Apgar score that
improved over time. Fortunately, both mother and baby
appear to be without long-term adverse effects.

IV Gentamicin Administered Epidurally
An anesthesia practitioner administered 450 mg of IV gentamicin via the epidural route to a woman in labor instead of
bupivacaine (0.125%). The pharmacy-prepared gentamicin
infusion had been removed from an ADC instead of the
intended bupivacaine infusion. Earlier, a pharmacy technician had incorrectly loaded 1 bag of the IV gentamicin in the
bin holding the epidural bupivacaine infusions.

Institute for Safe Medication Practices, Horsham, PA, USA

Corresponding Author:
Michael R. Cohen, President, Institute for Safe Medication Practices, 200
Lakeside Drive, Suite 200, Horsham, PA 19044, USA.
Email: mcohen@ismp.org

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