1. 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

2. Pharmacy department Southampton Pharmacy Research Centre (SPRC) Unintentional rapid infusion of lipid emulsion: Root cause analysis and changes to practice Caroline Cole Paediatric ICU & Nutrition Pharmacist

3. Pharmacy department Southampton 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

4. Pharmacy department Southampton 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

5. Pharmacy department Southampton 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

6. Pharmacy department Southampton Pharmacy Research Centre (SPRC) Proposed Solutions Nurse checking procedure revised New prescription forms introduced Sept 2013

7. Pharmacy department Southampton Pharmacy Research Centre (SPRC)

8. Pharmacy department Southampton Pharmacy Research Centre (SPRC)

9. Pharmacy department Southampton 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?

10. Pharmacy department Southampton Pharmacy Research Centre (SPRC) And finally… Communication & involvement of all relevant staff groups is essential Watch for new errors If you find yourself thinking “Not again!”…..