After a short time, the nurse observed the patient sleeping. The nurse told her that these symptoms were to be expected. Several hours later, the patient reported feeling flushed and nauseated. After administering a 6-g bolus dose, she started the infusion at 3 g/hour and hung a maintenance solution of Lactated Ringer’s solution at 300 mL/hour. The patient had actually received a 12-g loading dose fortunately, she recovered without permanent harm.Ī nurse retrieved two bags of Lactated Ringer’s solution from stock and added 40 g of magnesium sulfate to one bag. The nurse had misread the vial labels and had added too much magnesium sulfate to the IV bag. Concerned about toxicity, the physician ordered a test of the solution, which revealed a concentration of 80 g/L. The patient was flushed and nauseated, had shallow respirations, and was unable to move her extremities.
She returned 25 minutes later to find that the patient had received a 6-g loading dose. After remaining with the patient for 20 minutes, the nurse was suddenly called away. After the patient was taken to the busy, understaffed postpartum unit, she was later found in respiratory arrest and developed anoxic encephalopathy.Ī nurse prepared a bag of magnesium sulfate (40 g/L) and began an infusion at 200 mL/hour to deliver a 4-g bolus dose (100 mL) over 30 minutes. Because the mother had pre-eclampsia, a magnesium sulfate solution was already being infused when the second solution was hung. The mother was found unresponsive and has remained in a persistent vegetative state.īefore a patient was transferred to the postpartum unit, the nurse had accidentally replaced a mother’s depleted Lactated Ringer’s solution with an unlabeled liter bag of magnesium sulfate that had been prepared by another nurse for a different patient. The oxytocin solution was connected to the patient’s IV line, but the magnesium sulfate solution was started by mistake. Although the infusion had been administered during preterm labor, it remained connected at the patient’s Y-site-despite the fact that the infusion had been discontinued and was no longer being given. 1 Following are a few scenarios from their article:Ī nurse accidentally restarted an infusion of magnesium sulfate instead of beginning a new infusion of oxytocin after a mother had delivered her baby. Simpson and Knox described 12 cases in detail, revealing common precipitating events. 1 In the span of a few years, the authors, who have been involved in an ongoing review of obstetrical mishaps in the U.S., accumulated 52 reports of accidental overdoses of magnesium sulfate. Most of these errors were a result of unfamiliarity with safe dosage ranges and signs of toxicity, inadequate patient monitoring, mistakes in programming the pump, and mix-ups between magnesium sulfate and oxytocin.Ī detailed account of errors with magnesium sulfate has been published.
Yet many errors, some fatal, have been reported with this medication. P roblem: Practitioners who work in obstetrical units may feel assured in administering intravenous (IV) magnesium sulfate for treating preterm labor and pre-eclampsia.
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