Drug error in maternity care: a multiprofessional issue

Errors of drug administration, prescription and omission are a hidden phenomenon in maternity units. Clinical risk management reporting is often ineffective at detecting and monitoring such mistakes. The procedural and human errors that lie behind such incidents are rarely recognized and often compound one another. Substantial deficits in the clinical care of women following caesarean section were discovered. This audit focuses specifically on thromboembolic prophylaxis and post-operative analgesia. However, the findings highlight issues, which can be extrapolated to the problems of drug errors in general. This may be attributable to a combination of factors, including poor communication, bureaucracy around spheres of responsibility, inadequate local policies and an apparent disregard for the importance of accurate prescription and administration of medication. The audit also highlights profound inaccuracies in midwifery knowledge.