To Note: This paper refers mainly to the obstetric management of pregnant women but many of the risks and issues highlighted also relate to other clinical areas.
This bulletin has been developed by Wessex Academic Health Science Network on behalf of the Chief Pharmacists in the Wessex and Thames Valley areas and is endorsed by the Wessex Maternity, Children and Young People Strategic Clinical Network.
Executive Summary
Intravenous magnesium sulfate has the potential to cause serious harm or death when used incorrectly.
Evidence both nationally and locally indicates that patients are being exposed to significant risk when magnesium sulfate injections/ infusions are being prepared in clinical areas.
Because of the very serious risks associated with overdose, Trusts are advised NOT to have policies that require the dilution of 50% magnesium sulfate. Diluting 50% magnesium sulfate for injection is complicated and calculation errors are common.
It is safer, easier and potentially more efficient to use ready-made 10% or 20% magnesium sulfate preparations.
Trusts should now review their protocols and procurement arrangements to ensure that clinical areas are aware of the risks; that ready-to-use preparations are made available and staff using the preparations are supported in their safe use.
Please download the bulletin and poster below for full guidance.
