Jerry Fahrni

I was reading through the most recent issue of the ISMP Medication Safety Alert! and came across an incident where a CLINIMIX E solution was infused on a patient prior to being mixed, resulting in the patient receiving a concentrated dose of amino acids and electrolytes. Fortunately no harm was done.

CLINIMIX E is a dual chamber parenteral nutrition (PN) product consisting of two chambers separated by a seal. One chamber contains dextrose and calcium and the other chamber amino acids along with electrolytes. Simply bust the seal, mix the contents with some gentle agitation and hang it on the patient. Nothing could be easier. I loved these types of products when I used to work in the IV room. They don’t fit the bill for all patients, but when they do it sure makes life in the pharmacy simpler. Otherwise you have to make the PN from scratch which can be time consuming.

In the incident described in the ISMP article the CLINIMIX E bag was retrieved from the pharmacy after hours by nursing staff. This type of procedure is common in hospitals that don’t have a 24 hour pharmacy, i.e. small acute care hospitals. I think this type of system is dangerous, and certainly contributed to the mistake, but that’s not what stands out about this error.

The two things that really irritate me about this error are the physician’s directions and the nurses retrieving and starting a PN in the middle of the night. First and foremost, PN is never a life or death medication. Take a look at the ASPEN guidelines if you don’t believe me. PN is something that should only be used after serious consideration, and in a patient that has been NPO for several days. PN should never be used to adjust a patient’s electrolytes, temporarily augment a patients diet when they can eat solid food or to “stimulate appetite”. In this case if the patient needed PN it could have easily waited until morning. And second, the physician in this case wrote for the CLINIMIX E to be given “’if the patient does not eat at least 50% of breakfast.” For those of you that think this order is ok, raise your hand. Now everyone look around and find the people that raised their hands. Make a mental note to never allow them to treat you for anything serious. Again, PN is serious business and not something that should be started based on an “if, then” statement. Either start it or don’t, but don’t write orders for PN that may be interpreted more than one way depending on who’s looking at it.

Errors occur too frequently in hospitals now, we certainly don’t need to make committing them any easier.

August 12, 2010 issue of the ISMO Medication Safety Alert the issue of : “We have received a number of reports about the labeling of Xactdose unit dose liquid containers from VistaPharm, Inc., of Birmingham, AL. The company recently changed the way the drug concentrations are expressed on their labels. An example is phenytoin oral suspension which went from emphasizing 100 mg/4 mL to listing 125 mg/5 mL. The company rightly notes that the 125 mg/5 mL container delivers 100 mg or 4 mL (due to the heavy liquid consistency of phenytoin suspension), but the message doesn’t necessarily translate to nurses who are confused by the new label and need to give an exact dose. The good news is, we learned last week that VistaPharm is returning to the old style label. That will no doubt lead to less confusion, but nurses should also know not to rinse the residual suspension from the cup. Doing so would approximate as much as a 25% overdose. The company said they expect to release products with revised labeling by the end of the month.”
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