August 15, 2013: ALERT: Drug Shortages Highlight the Need for Independent Double Checks
ISMP Canada recently received a medication incident report describing errors in the revision of a master formula for total parenteral nutrition (TPN) at a healthcare organization that led to neonates receiving amounts of trace elements that were greater than intended. Trace elements are chemicals that the body requires in only minute amounts, including, for example, zinc, selenium, and manganese. In the incident reported to ISMP Canada, the healthcare organization had responded to a shortage of its usual zinc product by revising the TPN master formula to accommodate a new zinc formulation with a different concentration. Calculation errors were made during this process but were not discovered until a few months later. Fortunately, it appears that no adverse effects have occurred. The healthcare organization is conducting an extensive review to discover the underlying contributing factors.ISMP Canada has previously reported on the value of independent double checks in reducing the risk of medication incidents. Independent double checks have typically focused on high-alert medications; however this incident illustrates the value of such checks when alternative products (such as those with different doses or concentrations) are introduced into standard or established processes. The organization has distributed an interim safety alert to its practitioners about the merits of independent double checks based on previous ISMP Canada recommendations. The healthcare organization wanted to share this alert with other facilities to prevent a similar incident from occurring, especially given the current drug shortage situation, a setting in which the risk of a medication error is heightened.
