Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.

ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.

Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.

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