Terminology review: changing culture to reduce risk

Oxytocin (Syntocinon®) and ergometrine with oxytocin (Syntometrine®) are two well-known brands of oxytocics in current use in maternity centres within the UK. A recent incident alerted staff at University Hospital Southampton ([UHS], 2018) to the risks associated with the terminology being used to refer to these drugs. Further investigation highlighted that other maternity centres had also identified near misses and actual errors possibly resulting from the terminology being used (Figure 1 and Figure 2). The national reporting and learning system reported 1 157 patient safety incidences (Nurmahi, 2019) over a five-year period (2013–2018) involving Syntocinon® or Syntometrine®. Of these, 39 incidences resulted in the incorrect drug being given.

Health professionals are generally encouraged to use generic names for medicines and prescribing systems are often set up using generic names. Despite this recommendation, it is common practice to refer to these two drugs by their brand names. Staff working under pressure may inadvertently confuse the two products or misread the drug name due to the use of the prefix ‘synto’ for both products. A subsequent shortening of Syntocinon® to ‘synto’ in verbal communication has led to inadvertent administration of the wrong product. As a generic brand of oxytocin is also readily available, it is quite possible for staff to select Syntometrine® from the fridge when ‘synto’ is requested as this is the only product that resembles this name. This risk is likely to further increase as new members of staff, unfamiliar with the Syntocinon® brand of oxytocin, commence practice.