Abstract
Purpose: The purpose of this initiative was to proactively minimize the risk for patient harm related to errors in the administration of IV Pitocin and/or magnesium (Mg) during emergent situations in the labor and delivery unit, through best-practices and evidence-based strategies.
Background: Pitocin and Mg are high-risk IV medications in obstetrics, frequently given during stressful situations. After a serious Pitocin-related error at another facility caused adverse outcomes, the staff recognized their own vulnerability to similar mistakes. While quality improvement and risk management initiatives are often reactive responses to poor outcomes, the team chose a proactive approach. It implemented fail-safe solutions preemptively, rather than waiting for an incident to occur.
Method: The unit's nursing shared-governance council convened an interprofessional team of experts. This team performed a Failure Mode Effect Analysis (FMEA) focusing on the current Pitocin/Mg IV administration process. FMEA is a systematic, proactive method to identify and address process failure risks, prioritizing improvements before negative events occur. During the analysis, “failure modes” (FMs)–ways that the process can fail–were identified and assigned a risk profile number (RPN) by team consensus, adhering to FMEA methodology. Evidence-based interventions to mitigate FMs with RPNs >100 were determined. The process was then re-evaluated by team consensus to confirm risk reduction.
Results: The team included 3 labor and delivery nurses, the Nursing Professional Practice/Magnet Program Coordinator, the Director of Pharmacy and a nursing educator. Process mapping identified 6 steps in the Pitocin/Mg administration process during an emergent situation. A total of 8 FMs were identified within the process. Of these 8 FMs, 4 had RPNs >100 and were addressed. FM3 and FM4 were related to IV pump programming and each had a RPN = 280. The other 2 FMs were related to the point of delivery and each had a RPN = 512. Reevaluation of RPNs after evidence-based interventions demonstrated a decrease of between 71% to 98% indicating significant risk reduction.
Conclusion: Nursing excellence requires adoption of proactive approaches such as FMEA to prevent harm and promote patient safety. Quality improvement should be a forethought rather than a process set into play after the fact, and clinical nurses are well-positioned to lead the implementation of these initiatives.
Notes
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References:
1. Anjalee, J. A. L., Rutter, V., & Samaranayake, N. R. (2021). Application of Failure Mode and Effect Analysis (FMEA) to improve medication safety: a systematic review. Postgraduate Medical Journal, 97(1145), 168–174. https://doi.org/10.1136/postgradmedj-2019-137484
2. Giuliano, K. K. (2018). Intravenous Smart Pumps: Usability Issues, Intravenous Medication Administration Error, and Patient Safety. Critical Care Nursing Clinics of North America, 30(2), 215–224. https://doi.org/10.1016/j.cnc.2018.02.004
3. Institute for Healthcare Improvement. (2025). Failure Modes and Effects Analysis (FMEA) Tool. Ihi.org. https://www.ihi.org/library/tools/failure-modes-and-effects-analysis-fmea-tool
4. Khalil, H., Kynoch, K., & Hines, S. (2020). Interventions to ensure medication safety in acute care. International Journal of Evidence-Based Healthcare, Publish Ahead of Print(2). https://doi.org/10.1097/xeb.0000000000000232
5. Larmené-Beld, K. H. M., Keers, R. N., & Taxis, K. (2020). A survey about label enhancement methods for parenteral medication in European hospital pharmacies. European Journal of Clinical Pharmacology, 76(11), 1567–1571. https://doi.org/10.1007/s00228-020-02916-x
6. Laxton, V., Maratos, F. A., Hewson, D. W., Baird, A., Archer, S., & Edward J.N. Stupple. (2024). Effects of colour-coded compartmentalised syringe trays on anaesthetic drug error detection under cognitive load. British Journal of Anaesthesia, 132(5). https://doi.org/10.1016/j.bja.2023.12.033
7. de Kassio Nunes, G., Campos, J. F., & da Silva, R. C. (2022). Intravenous therapy device labeling in Intensive Care Units: an integrative review. Revista Brasileira de Enfermagem, 75(6). https://doi.org/10.1590/0034-7167-2022-0049
8. de Kassio Nunes, G., Malta Souza Antunes, L., Nogueira da Silva, R., & Celestino da Silva, R. (2023). Labelling of intravenous drug delivery devices in critically ill patients: A scoping review. Nursing in Critical Care, 29(2). https://doi.org/10.1111/nicc.12994
9. Pinkney, S. J., Fan, M., Koczmara, C., & Trbovich, P. L. (2019). Untangling Infusion Confusion. Critical Care Medicine, 47(7), e597–e601. https://doi.org/10.1097/ccm.0000000000003790
10. de Souza, N. M. G., da Silva, V. M., Lopes, M. V. de O., Diniz, C. M., & Ferreira, G. de L. (2019). Evaluation of color-coded drug labeling to identify endovenous medicines. Revista Brasileira de Enfermagem, 72(3), 715–720. https://doi.org/10.1590/0034-7167-2018-0242
11. Weber, L., Schulze, I., & Jaehde, U. (2022). Using failure mode and Effects Analysis to increase patient safety in cancer chemotherapy. Research in Social and Administrative Pharmacy, 18(8). https://doi.org/10.1016/j.sapharm.2021.11.009
Sigma Membership
Phi Gamma (Virtual)
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Quality Improvement
Research Approach
Translational Research/Evidence-based Practice
Keywords:
Acute Care, Interprofessional Initiatives, Interpersonal Relations, Patient Safety, Oxytocin, Medication Errors, Medication Error Prevention, Drug Administration, Labor (Obstetrics)
Recommended Citation
Ritzema, Cristina L. and Schweitzer, Jessica, "Staying Ahead of Murphy’s Law: A Proactive Approach to Quality Improvement" (2026). International Nursing Research Congress (INRC). 279.
https://www.sigmarepository.org/inrc/2026/presentations_2026/279
Conference Name
37th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Toronto, Ontario, Canada
Conference Year
2026
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-09-21
Staying Ahead of Murphy’s Law: A Proactive Approach to Quality Improvement
Toronto, Ontario, Canada
Purpose: The purpose of this initiative was to proactively minimize the risk for patient harm related to errors in the administration of IV Pitocin and/or magnesium (Mg) during emergent situations in the labor and delivery unit, through best-practices and evidence-based strategies.
Background: Pitocin and Mg are high-risk IV medications in obstetrics, frequently given during stressful situations. After a serious Pitocin-related error at another facility caused adverse outcomes, the staff recognized their own vulnerability to similar mistakes. While quality improvement and risk management initiatives are often reactive responses to poor outcomes, the team chose a proactive approach. It implemented fail-safe solutions preemptively, rather than waiting for an incident to occur.
Method: The unit's nursing shared-governance council convened an interprofessional team of experts. This team performed a Failure Mode Effect Analysis (FMEA) focusing on the current Pitocin/Mg IV administration process. FMEA is a systematic, proactive method to identify and address process failure risks, prioritizing improvements before negative events occur. During the analysis, “failure modes” (FMs)–ways that the process can fail–were identified and assigned a risk profile number (RPN) by team consensus, adhering to FMEA methodology. Evidence-based interventions to mitigate FMs with RPNs >100 were determined. The process was then re-evaluated by team consensus to confirm risk reduction.
Results: The team included 3 labor and delivery nurses, the Nursing Professional Practice/Magnet Program Coordinator, the Director of Pharmacy and a nursing educator. Process mapping identified 6 steps in the Pitocin/Mg administration process during an emergent situation. A total of 8 FMs were identified within the process. Of these 8 FMs, 4 had RPNs >100 and were addressed. FM3 and FM4 were related to IV pump programming and each had a RPN = 280. The other 2 FMs were related to the point of delivery and each had a RPN = 512. Reevaluation of RPNs after evidence-based interventions demonstrated a decrease of between 71% to 98% indicating significant risk reduction.
Conclusion: Nursing excellence requires adoption of proactive approaches such as FMEA to prevent harm and promote patient safety. Quality improvement should be a forethought rather than a process set into play after the fact, and clinical nurses are well-positioned to lead the implementation of these initiatives.
Description
Murphy’s Law dictates that whatever could go wrong, will go wrong! So why wait until the worst happens before implementing evidence-based solutions? Learn about how an interprofessional team lead by nurses took preemptive steps to reduce the risk of harm to patients in the obstetrics unit.