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
Pharmacy departmentSouthampton Pharmacy Research Centre (SPRC)
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
Pharmacy departmentSouthampton Pharmacy Research Centre (SPRC)
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
Pharmacy departmentSouthampton Pharmacy Research Centre (SPRC)
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
Pharmacy departmentSouthampton Pharmacy Research Centre (SPRC)
Proposed Solutions
• Nurse checking procedure revised • New prescription forms introduced Sept 2013
Pharmacy departmentSouthampton Pharmacy Research Centre (SPRC)
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?