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Alert: Concentrated Electrolyte Products During Drug Shortages

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 mEq.

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Patient Identification Errors in Infants and Neonates

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.

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CHPSO Annual Evaluation Released – General Trends and Analyses

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 here to access the Annual Report overview webinar recording.