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Safety Science Principles for Administration of Oxytocin and Magnesium Sulfate in Labor & Delivery Units


The Institute of Safe Medication Practices has listed Oxytocin and Magnesium sulfate as high-alert medications causing significant harm to patients when used in error. Since these medications are frequently used in Labor & Delivery (L&D) units, safe administration to prevent medication errors is necessary for these units.

As a part of the Safety Program for Perinatal Care (SPPC) of the Agency for Healthcare Research and Quality (AHRQ), several L&D units opted for implementing safety science principles for the safe administration of oxytocin and magnesium sulfate.

The research team led by Kayla B Gray has published a qualitative research article in the Research on Women’s Health Journal, which describes the experiences of 25 L&D units, which have opted to implement the safety science principles for the safe administration of these medications.

Ensuring the safe use of oxytocin and magnesium sulfate and reducing medication errors involve the application of specific strategies and systematic approaches. The SPPC has been designed to improve the safety culture of L&D units by applying safety science principles, which include standardization strategies, teamwork & communication, independent checks, learning from defects, and in situ simulation training.

To evaluate the SPCC implementation, the researchers used several data sources. A web-based reporting tool was used to monitor the application of the safety science principles, prior to the program implementation, during, and 10 months after the beginning of implementation. To assess the implementation experiences, the researchers conducted semi-structured interviews with the participating L&D unit teams.

The L&D units participated in the program achieved successful implementation of the safety science principles. For oxytocin administration, there was an improvement in all the five safety science principles, whereas, for magnesium sulfate, improvements were observed in three of the five principles.

The L&D units achieved 100% standardization in their policies and procedures for safe medication administration. There was a considerable increase in the use of independent checks, which was 82% for oxytocin and 78% for magnesium sulfate. Teamwork and communication improved to 95% for oxytocin and 78% for magnesium sulfate administration. Learning from defects enhanced to 91% for oxytocin administration but remained unchanged at 67% for magnesium sulfate. However, only one-third of the participants utilize the in situ simulation.


Based on the study, the researchers are hopeful that the application of safety science principles for the administration of safe medication may provide an effective approach to improve medication safety in L&D units. Even though there were many other high-risk medications, oxytocin and magnesium sulfate were considered for this program because these two were the most frequently used high-risk medications in L&D units and the consequences of errors from the use of these medications were more harmful to the patients. Similar strategies and approaches could also be applied to other medications and achieve benefits. The limitation of this study is that the case number is too small. However, the researchers envisage that the future research may benefit from a study with the participation of a large number of L&D units with longer implementation period, as well as the inclusion of a comparison group.


Kayla B Gray, Asta V Sorensen, Samantha A Sommerness, Kristi K Miller, Hannah Margaret Clare, Kamila Mistry, Leila Kahwati. Implementation Experiences with Improving Safe Medication Practices for Oxytocin and Magnesium Sulfate during Labor and Delivery. Research on Women’s Health 2018;1(1):2. [View Article]