Standardize When Possible (CUSP Science of Safety) (continued) Key Perinatal Safety Elements Examples Standardize magnesium sulfate dosing a calibrated infusion pump with free-flow protection. (continued) If a infusion pump with these safety features is not available, then loading dose should be administered via a separate bag. Premixed or pharmacy-prepared bags (e.g., 4 g/100 ml or 8 g/100 ml) should be used unitwide to reduce variability and risk of error. The same standard preparation either premixed or pharmacy-prepared bags (e.g., 20 g/500-ml bag) unitwide for maintenance infusion.13 Use of a 500-ml bag can help distinguish the bag from liter bags containing fluids or other medications.11 The smaller volume also reduces the amount of magnesium that can be delivered in the event of an accidental rapid infusion (e.g., pump programming error or failure). Complete removal of the line from the intravenous (IV) port when magnesium sulfate therapy is discontinued to avoid accidental infusion.10,11 Use uniform parameters for maternal and fetal monitoring and provider notification prior to initiation of magnesium sulfate and during infusion. The use of uniform parameters for fetal and maternal monitoring and provider notification before and during magnesium sulfate use minimizes variability across providers and nursing staff in order to reduce the risk of error. Standardize laboratory reporting of serum magnesium levels. Hospital policy and process for uniform reporting of serum magnesium levels. Magnesium levels can be reported as milligrams per deciliter (mg/dL), milliequivalents per liter (mEq/L) and millimoles per liter (mmmol/L), and the same magnesium level would be reported using different numbers depending on the unit of measure. Bedside staff, providers, and lab personnel should agree on one unit for reporting and communicating magnesium levels to avoid miscommunication and delays in timely care.10 Create Independent Checks (CUSP Science of Safety) Key Perinatal Safety Elements Examples
Key Perinatal Safety Elements Examples/customizable components High-reliability teams: (continued) Manage conflict using a constructive positive approach to emphasize “what is right, not who is right”: D: Describe the specific behavior or situation. E: Express how the situation you feel or concerns you. S: Suggest other alternatives. C: Consequences stated in terms of team goals, not punishment. Patient and Family Engagement (CUSP) Key Perinatal Safety Elements Examples/customizable components Discuss and benefits of intrapartum or postpartum magnesium sulfate use. Use unit-established process for conveying risks and benefits of magnesium sulfate use to patient and family. Educate patient/family regarding magnesium sulfate use. Use unit-established approach for nursing-led patient education regarding magnesium sulfate infusion, mobility restrictions, and expected effects. Educate patient and family concerning frequency of nursing assessment and monitoring, signs and symptoms to report to nursing staff. Provide instructions for reporting signs and symptoms to nursing staff. References Doyle LW, Crowther CA, Middleton P, et al. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD004661. Review. PMID: 19160238. Duley L, Gülmezoglu AM, Henderson-Smart DJ, et al. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev. 2010 Nov 10;(11):CD000025. doi: 10.1002/14651858.CD000025.pub2. Review. PMID: 21069663. American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No. 652: Magnesium sulfate use in obstetrics. Obstet Gynecol. 2016 Jan;127(1):e52-3. doi: 10.1097.AOG. 0000000000001267. PMID: 26695587.
3. Administration (cont'd) When bolus is complete, initiate a premixed maintenance bag with a concentration of 20 grams of per 500 ml. Administer maintenance infusion at a rate of (check one)— ___1 gram/hour (25 ml/hour) ___1.5 grams/hour (38 ml/hour) ___2 grams/hour (50 ml/hour) ___Other (separate provider order required for rates other than the above rates) the magnesium sulfate line with appropriate medication sticker. Do not infuse other medication into the magnesium sulfate line. Second must verify pump settings and line hookup whenever there is a rate change or a new bag is hung. When the order for magnesium is discontinued, the pump should be stopped and the bag and IV tubing promptly disconnected from the patient and discarded. 4. Provider notification parameters and standing orders for responding to suspected magnesium toxicity Notify the primary maternity care provider if any of the following conditions occur: changes from baseline more than 20 mmHg SBP or 10 mmHg DBP mmHg pulse >120 bpm or < 60 bpm respiration < 14 or > 24 oxygen saturation < 95% urine output less <30 ml/hour increasing proteinuria increasing clonus DTRs 4+ persistent headache or visual disturbances increasing swelling of face, hands, or feet presence/worsening of epigastric (right upper quadrant pain) increasing nausea/vomiting bruising vaginal bleeding Activate a response AND notify the primary maternity care provider for— signs and symptoms of magnesium toxicity seizure Signs and symptoms of magnesium toxicity include respiratory depression (less than 12 respirations/minute), prolonged expiration, severe chest heaviness or shortness of breath, a significant decrease in the level of consciousness, the absence of deep tendon reflexes, and a significant decrease in the patient’s pulse or blood pressure.