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?
(more…)