{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T21:17:16Z","timestamp":1791407836244,"version":"4.3.3"},"reference-count":14,"publisher":"SAGE Publications","issue":"4","license":[{"start":{"date-parts":[[2026,1,5]],"date-time":"2026-01-05T00:00:00Z","timestamp":1767571200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Hosp Pharm"],"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:p>A patient at our institution was admitted to Labor &amp; Delivery at 41-weeks\u2019 gestation for augmentation of early labor for spontaneous rupture of membranes. The anesthesia team placed an epidural catheter and initiated an infusion of bupivacaine with fentanyl for pain management. During nursing shift change several hours later, staff found oxytocin connected to the patient\u2019s epidural catheter. A root cause analysis identified that a combination of human error, workflow inefficiencies, and technology challenges contributed to this error. Because the neuraxial and oxytocin infusion bags were the same size, the Department of Pharmacy recommended switching oxytocin infusion bags to a more distinct size. We summarize the literature on inadvertent neuraxial medication infusions, which can lead to devastating consequences. While this patient experienced no adverse effects, we present this case as a cautionary case study to highlight the need for system-level interventions to enhance patient safety.<\/jats:p>","DOI":"10.1177\/00185787251408703","type":"journal-article","created":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T07:05:36Z","timestamp":1767683136000},"page":"327-332","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":2,"title":["Inadvertent Administration of Oxytocin via Epidural"],"prefix":"10.1177","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-7370-7687","authenticated-orcid":false,"given":"Alexandra","family":"Tcherepanova","sequence":"first","affiliation":[{"name":"Boston University, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel","family":"Achu-Lopes","sequence":"additional","affiliation":[{"name":"Chobanian and Avedisian School of Medicine, Boston, MA, USA"},{"name":"Boston Medical Center, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Niamh","family":"OGrady","sequence":"additional","affiliation":[{"name":"Boston Medical Center, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8332-8145","authenticated-orcid":false,"given":"William","family":"Vincent","sequence":"additional","affiliation":[{"name":"Boston Medical Center, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamed T.","family":"Sarg","sequence":"additional","affiliation":[{"name":"Boston Medical Center, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3499-3456","authenticated-orcid":false,"given":"Karolina","family":"Brook","sequence":"additional","affiliation":[{"name":"Chobanian and Avedisian School of Medicine, Boston, MA, USA"},{"name":"Boston Medical Center, MA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,1,5]]},"reference":[{"key":"e_1_3_2_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2022.06.017"},{"issue":"6","key":"e_1_3_2_3_2","first-page":"355","article-title":"Pain management in labor","volume":"103","author":"Smith A","year":"2021","unstructured":"Smith A, Laflamme E, Komanecky C. Pain management in labor. Am Fam Physician. 2021;103(6):355-364.","journal-title":"Am Fam Physician"},{"key":"e_1_3_2_4_2","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0000000000000118"},{"key":"e_1_3_2_5_2","unstructured":"Osilla EV Patel P Sharma S. Oxytocin. StatPearls [Internet]. February 15 2025. Accessed September 2 2025. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK507848\/"},{"key":"e_1_3_2_6_2","doi-asserted-by":"publisher","DOI":"10.1111\/cns.12551"},{"key":"e_1_3_2_7_2","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0000000000000539"},{"key":"e_1_3_2_8_2","doi-asserted-by":"publisher","DOI":"10.5694\/j.1326-5377.2000.tb125570.x"},{"key":"e_1_3_2_9_2","doi-asserted-by":"crossref","unstructured":"Chowdhury P Dabrowska D Said H. \u201cEternal vigilance is the price of safety\u201d: a case of inadvertent administration of oxytocin via epidural catheter. Eur J Anaesthesiol. 2014;31:178. Accessed September 2 2025. https:\/\/journals.lww.com\/ejanaesthesiology\/fulltext\/2014\/06001\/_eternal_vigilance_is_the_price_of_safety___a_case.505.aspx","DOI":"10.1097\/00003643-201406001-00505"},{"key":"e_1_3_2_10_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X0303100108"},{"key":"e_1_3_2_11_2","unstructured":"Lefebvre PA Meyer P Lindsey A Jew R Rebello E. Unraveling a recurrent wrong drug-wrong route error\u2014tranexamic acid in place of bupivacaine: a multistakeholder approach to addressing this important patient safety issue. APSF Newslett. 2024;39(2):39-41. Accessed July 7 2025. https:\/\/www.apsf.org\/article\/unraveling-a-recurrent-wrong-drug-wrong-route-error-tranexamic-acid-in-place-of-bupivacaine\/"},{"key":"e_1_3_2_12_2","doi-asserted-by":"publisher","DOI":"10.1111\/anae.14662"},{"key":"e_1_3_2_13_2","unstructured":"Institute for Safe Medication Practices (ISMP). ISMP Targeted Medication Safety Best Practices for Hospitals. ISMP; 2024. 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