Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error

Int J Obstet Anesth. 2006 Jan;15(1):63-7. doi: 10.1016/j.ijoa.2005.06.009. Epub 2005 Oct 26.


We present two reports of pregnant women in labor who inadvertently received a magnesium sulfate solution in their epidural space. Both women received approximately 9 mg of magnesium sulfate, and neither of them demonstrated any signs or symptoms of focal neurological toxicity. Once the mistakes were discovered and appropriate medication was delivered, the patients attained an acceptable level of analgesia.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Analgesia, Epidural*
  • Analgesia, Obstetrical*
  • Analgesia, Patient-Controlled*
  • Epidural Space
  • Female
  • Humans
  • Magnesium Sulfate / administration & dosage*
  • Medication Errors*
  • Pregnancy


  • Magnesium Sulfate