Prenteral nutrition error [from #ISMP]

From the latest ISMP Medication Safety Alert!, a mix up between an adult parenteral nutrition (PN) template in an electronic health record (#EHR) and one for pediatrics.

The big difference between these two is how you order electrolytes; it’s a really big difference.

The most shocking part of all this was that the error made it’s way through the physician that ordered it, a pharmacist that “entered the PN order” (I’m assuming in the compounding application), the “trained technician” that prepared it – missing the fact that the bag contained a whooping 2600mL of sterile water, the pharmacist that checked it, and finally the nurse that hung it. Swiss cheese anyone?

Of all the people involved I blame the two pharmacists that touched it the most followed by the technician that made it. You really can’t put the blame on the nurse as the intricacies of PN formulation really isn’t their expertise; it the pharmacists. And didn’t any of the CDS systems give them a warning that the PN formula sucked? Should have.

Check out the PN numbers in the image to the right. Numbers like that should have sent chills up the pharmacists spine. And the fact that the technician had to change sterile water bags in the middle of the compounding process should have also been a clue that something was wrong.

Fortunately the patient wasn’t harmed. “After the correct PN solution was started, the erroneous solution was sent to the pharmacy for analysis. The osmolarity of the incorrectly compounded solution was found to be exceedingly hypotonic at 138 mOsm/L. Thankfully, the patient did not experience any adverse effects from the error. He continued receiving correctly compounded PN for several days and was later discharged from the hospital.”

Dude, just when I think there’s a great argument against the obsolescence of pharmacy as a profession something like this happens. We’re drug experts for Pete’s sake. It’s our job to prevent crap like this from happening, not perpetuate the error. Everyone makes mistakes, it’s human nature. But this error made wound its way through three people in the pharmacy. That’s a problem.