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An audit into the prescription of syntocinon and magnesium sulphate infusions
  1. T Hunjan,
  2. T Glyn
  1. University of Bristol, Bristol, UK


Background Obstetric negligence cases are the most expensive for the NHS.1 In particular, medication errors were the second most common incident reported in a recent survey by the National Patient Safety Agency.2 In light of these findings, this audit was performed to determine the extent to which Syntocinon and magnesium sulphate infusion prescriptions in the Obstetrics Department at St Michael's Hospital, Bristol, conform to the Trust Prescribing Guidelines.

Method The medical records of 30 women who had received Syntocinon (during May 2009) and 23 who had received magnesium sulphate (May 2008–June 2009) were reviewed. 12 standards were drawn from local prescribing policies3,,5 and the extent to which each prescription met the standards was recorded.

Results Importantly, in 6/76 cases, the drug infusion was administered, but not actually prescribed. The audit identified significant shortcomings in prescription writing. The standards least well adhered to were legibility (53%–70% of cases), the use of block capitals (13%–27%) and the identifiability of the prescriber (13%–27%). For magnesium sulphate, there was also frequent use of abbreviations (70%–83%).

Recommendations/Actions To draw attention to the inadequacies in prescribing, a poster was created and displayed on the Delivery Suite. The relevant prescribing policies should be readily available on the wards. The Trust fluid chart was redesigned and stickers for the prescription of the two drug infusions were approved for production by the Central Delivery Suite working party. A re-audit should be carried out 6 months after implementation.

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