Patient dies of Mag sulfate overdose

Published

At another facility in a neighboring town they had a young mom die of a mag sulfate overdose a few hours after being admitted, she was being treated for preterm labor. The news reports say that this was an experienced nurse with 8 years of L&D experience. Just curious what your facilitys Mag protocols include?

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Specializes in Gastroenterology; and Primary Care.

Which facility did this occur? I work in a Tampabay area hospital.

I only heard of the one inccident.

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Which facility did this occur? I work in a Tampabay area hospital.

I only heard of the one inccident.

Plant City...I just found an earlier post about this incident. Sorry to bring it up again!!

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Specializes in Gastroenterology; and Primary Care.

Oh, thank God I thought it happened again somewhere else.

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The Mag hung is premixed, nurses are no longer allowed to mix it on the unit. (40 g in 1000 cc NS).

Two nurses must be present and verify pump settings on initiation of the loading dose and change to maintenance rate. This is documented on the medication card.

Coordinator or charge nurse visits each patient every shift and documents current rate on the chart. Done as a second check.

Mag is considered a high alert drug. That death prompted the change of the coordinator or charge nurse checking the current dose.

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At our facility if it daytime work hours then the pharmacy will mix and send our MGSO4 to the unit - but if it's night shift and we are just starting the MGSO4 we mix it up ourselves following very specific standing orders, then it must be co-signed and pump rate checked by a 2nd RN prior to hanging.

This is how we mix it - loading dose ( whether it's 4g,5g,6g depending on dr. order) goes in 250ml NS and ran over 30 minutes. Then for maintanece dose we take a 100ml bag of NS - withdraw 20ml NS and disgard and then ad 10gm MGSO4 / 20ml ( 5gm/10ml) - and run it at whatever the the maintance rate the DR wants - 2gm/hr = 20ml/hr, 3gm/hr=30ml/hr etc. NEVER is it mixed in larger bags then 100ml for maintance or 250ml for loading. Years ago the pharmacy used to mix it in a full 1000ml iv bag - but then policy was changed to reduce risk of OD. - We do Mg levels 2 hrs after load and then q 6 hr RTC. VS q 15 through load then q 1hr, w/ DTR's & LS, then once in therapeutic range (according to mg level, dtr's) q4hr VS, DTR & LS. Our standing orders include cont EFM, Foley, 3000ml/24h fluid restriction, have CA gluconate at bedside ( which is kinda pointless since according to multiple resources including PCEP it needs to be given by ACLS certified- which none of us OB RN's are). Anyhow - thats all i can think of about our policy off hand. HTH.

OBNurseryRN2006

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Thanks to all who have responded, we are looking at our Mag protocols and want to make sure that something like this never happens at our facility. Please let me know what your hospital does, and what your protocols include.

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Specializes in Trauma, Teaching.

There's quite a long thread on this under the "nursing news" thread, a lot of people have posted their hospitals' procedures.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Here is the link to that thread:

https://allnurses.com/forums/f195/overdose-magnesium-sulfate-kills-18yo-mom-labor-161884.html?highlight=Overdose+Magnesium+Sulfate

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