Common sense prevents IV magnesium mistakes
Here’s a helpful hint from the folks at the Institute for Safe Medication Practices: Use common sense when it comes to checking doses.
Case in point: an incident of magnesium sulfate poisoning, in which a doctor changed his mind about the dose, crossing out a "2" in front of grams and replacing it with a "5." The nurse thought he wrote 51 grams and checked with the pharmacist. Unbelievably, the pharmacist assured her the dose was OK. It wasn’t.
For an hour the patient received the super- concentrated magnesium solution, at which time she complained of paralysis and almost fainted. Emergency care saved her, despite a serum magnesium level at least five times normal.
Another near-tragedy occurred when a nurse programmed an automatic pump to deliver a bolus of 310 ml of a magnesium sulfate IV, instead of 30 ml of the solution in an hour. The patient almost died, having received eight grams of drug.
The final magnesium horror story involved a dosing error that never reached a patient. But it passed through a pharmacy technician and a pharmacist before it was caught by a second pharmacist reviewing orders. The pharmacy technician misread an order for 10 mEq of magnesium as 10 ml of magnesium solution equivalent to 40 mEq of the drug.
The ISMP recommends that any time an injectable order calls for the use of more than two vials of drug, it’s a good idea to double-check the order. The nurse needed five vials of magnesium to comply with that 51 g order. If hospitals plan to buy programmable equipment like automatic infusers make sure they’re easy to use. Finally, ISMP recommends eliminating floor stock of magnesium; replace it with premixed solutions.
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