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.
Conversely, referring to the combination product by its generic name (ergometrine and oxytocin), or vice versa, runs the risk of it being mistaken as just one or other of the ingredients rather than the combination product Syntometrine®. In this instance, use of the brand name is justified to avoid selection of either of the ingredients ergometrine or oxytocin as a single agent product rather than the combined product, Syntometrine®.
The matter was raised with key stakeholders working within the gynaecology and maternity unit in the hospital; the risk and patient safety group, and the trust's medicines safety officer were also consulted with (Nurmahi, 2018). It was agreed that a culture change was required around the current terminology in use amongst health professionals using Syntocinon® and Syntometrine®. The practice was, however, so embedded in everyday practice amongst staff, it was recognised that this would take time to change. Furthermore, any change would be subject to all stakeholders engaging with the recommendations.
Within the UHS maternity unit, a change in practice has begun: the written use of the term Syntocinon® on notice boards and guidelines is being removed and staff are regularly being reminded of the change and are encouraged to challenge colleagues if they use the incorrect terminology. All new midwives, as part of their preceptorship training, are being made aware of the risks associated with the use of the name Syntocinon® and its subsequent shortening to ‘synto’ (Nurmahi, 2020).
Since starting this initiative, no patient at UHS (2020) has received the wrong product due to confusion over the name. As this is an issue that impacts other centres outside the trust, the initiative was shared with the UK Clinical Pharmacy Association (UKCPA) Women's Health Group with a view to disseminate this change in practice more widely across the UK. A briefing document was drawn up with the following recommendations (UKCPA, 2019):
The recommendations have been endorsed by the Royal College of Midwives, Royal College of Nursing and the Royal Pharmaceutical Society, as well as having received support from the Royal College of Anaesthetists, and the Royal College of Obstetricians and Gynaecologists. It is hoped that success at UHS will encourage national uptake, ultimately reducing medication errors and improving patient safety.
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