Example from CHPSO database: Due to a shortage of the
premixed electrolyte solution bags used in the NICU, pharmacy had
a process to compound the product if needed. The process,
including the compounding recipe and labels were adopted from a
sister facility. While compounding magnesium sulfate, a
pharmacist discovered that the concentration in the vials at the
sister facility was different than the concentration typically
available at this facility.. This led to the compounding of a bag
containing a total of 4.7 mEq magnesium sulfate instead of 0.75
Incidents involving misidentification resulting in infants
undergoing unnecessary surgical procedures appear in the news
with surprising frequency. As recently as 2016,
an infant in Tennessee underwent an unnecessary frenulectomy.
Last month, CHPSO members received their hospital-specific 2017
Annual Evaluation and Analysis, which covers the period January 1
– December 31, 2017, focusing on a sample of submitted events.
These reports included elements such as the number of events by
type, the harm reporting ratio of events submitted, and an
analysis of the tone and content of the events. For more detailed
information on what is included in these evaluations, click
to access the Annual Report overview webinar recording.