Safety alert over 25 serious incidents linked to common drug

Maternity services have been issued with a national patient safety alert over inappropriate use of a common labour-inducing drug following a review of 25 serious incidents.

NHS England’s national patient safety team, backed by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and the Royal College of Anaesthetists, has issued an official alert instructing all providers to stop pre-preparing oxytocin infusions at ward level, in all clinical areas.

Trusts must complete this and three other actions by 31 March 2025. Oxytocin is one of the most commonly used drugs in labour and childbirth and can be administered to initiate contractions. In a much higher dose, it can treat postpartum haemorrhage, severe bleeding after birth. 

The inadvertent administration of a postnatal dose of oxytocin before a baby is born can lead to significant harm to mother and baby.

Safety reports into deaths and harm in maternity services, including the Ockenden reports into Shrewsbury and Telford Hospitals Trust and the seminal case which prompted the East Kent inquiry, that of Harry Richford, mention inappropriate use of oxytocin.

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Source: HSJ, 24 September 2024