Nine cases of unintentional rapid infusion of lipid emulsion in children: root cause analysis and changes…

Nine cases of unintentional rapid

infusion of lipid emulsion in children: root cause analysis

and changes to practice

Caroline Cole, Paediatric Clinical Pharmacist, Southampton Children’s Hospital

Pharmacy departmentSouthampton Pharmacy Research Centre (SPRC)

Unintentional rapid infusion of lipid emulsion:

Root cause analysis and

changes to practice

Caroline ColePaediatric ICU & Nutrition

Pharmacist


The problem Lipid – Not Again!

• The trigger – 3 identical incidents in 3 months• Database search - 43 PN incidents reported

since 2004 in children (2 per 1000 PN days)

– 20 reports of incorrect administration– 9 cases of rapid infusion of lipids (age 3mo-9yr)

• 8 due to switching lipid and aqueous rates• 1 due to entering daily volume as hourly volume to

infuse


Potential harm

Over-infusion of lipid

• Hyperlipidaemia• Fever, irritability,

tachycardia• N & V, pancreatitis• Deranged LFTs, jaundice• Respiratory distress,

metabolic acidosis• Coagulopathy, anaemia

Under-infusion of aqueous bag

• Fluid & electrolyte disturbances

• Hypoglycaemia• Compromised nutrition


Contributory factors identified by root cause analysis

Pharmacy factors• Paediatric PN

compounded with separate lipid bag

• Prescription form administration instructions

• Time PN delivered to ward

Nurse factors• Nurse checking

procedure• Timing of PN

administration• Workload pressures

– increasing number of PN patients & complexity of patients

– Limited number of iv trained nurses per shift


Proposed Solutions

• Nurse checking procedure revised • New prescription forms introduced Sept 2013




Proposed Solutions

• Nurse checking procedure revised • New prescription forms introduced Sept 2013• PN ordered in advance for stable patients• Education & training

– Nurse induction & iv training assessments include PN– Review incidents regularly and feedback via M&M meetings

• Other suggestions: – Investigate availability of suitable all-in-one formulation– Role of Smart pumps? – Cohort patients?


And finally…

• Communication & involvement of all relevant staff groups is essential

• Watch for new errors• If you find yourself thinking “Not again!”…..

Nine cases of unintentional rapid infusion of lipid emulsion in children: root cause analysis and changes…

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