Issue 1
Death Associated with an IV Compounding Error and Management of Care in a Naturopathic Centre
This bulletin follows an incident reported to ISMP Canada of a cancer patient receiving a fatally high dose of selenium as part of an intravenous complex tissue- and wound-healing formulation at a complementary care center (CCC). The selenium solution was prepared by a compounding pharmacy and was added to the formulation on site at the CCC. Key opportunities for improvement were the compounding processes at the pharmacy, and the emergency response, and preparation, storage and administration of the admixture at the CCC.
Key Words:
- Complementary medicine, alternative medicine
- Naturopathy, naturopathic medicine
- Confirmation bias
- Microgram vs milligram
- Dangerous abbreviation
- Dose error
- 1000-fold overdose
- Weigh scale
- Conversion calculation
- Preprinted order sets
- Compounding
- Emergency response
- Vital monitoring
𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Stakeholder Consultation on Naming of Biologic Drugs
- Caution: Unlabelled Marking on a Vaccine Syringe Led to Under-dosing of Adult Patients