Nearly 200 patients affected by supplement mix-up, AHS calls for review
Published Friday, April 26, 2013 1:15PM MDT
Last Updated Friday, April 26, 2013 6:25PM MDT
The province is reviewing protocols after nearly 200 neonatal and pediatric patients at three Edmonton hospitals were given incorrectly-mixed nutritional supplements.
Alberta Health Services made the announcement Friday, saying 186 patients received incorrectly mixed ‘total parenteral nutrition’ supplements at the University of Alberta Hospital, Grey Nuns and Misericordia between mid-December and April 12.
“We are deeply sorry for the concern this has caused to our families and patients,” said Dr. Verna Yiu, chief medical officer of quality and medical affairs.
"I want to stress that there have been no deaths, illnesses or injuries as a result of this error. The chance of any babies developing any complications as a result of this error are extremely low."
The province says there is no evidence of adverse effects for those who received the nutritional supplement.
The supplement, which contains elements of zinc, selenium, copper and chromium, is given to premature babies, children and adults who are sick and can’t receive adequate nutrition through other means.
The calculation error means two times the prescribed dose of each component in the supplement was incorporated.
"However, none of the patients received doses that were above the recommended maximum levels," Yiu said.
'Trying to make sure it never happens again'
Doctors believe a manufacturer that provides an ingredient in the mix may have changed its concentration, throwing off the 'master recipe,' but say it's hard to pinpoint where the error occurred due to the number of people involved.
"As you can imagine, that is a very complicated process, many people involved, all the way from the ordering physician through to pharmacy, preparation and back again," said Dr. David Mador, medical director for Edmonton.
"This type of care is complicated and errors can happen. Our focus right now is on understanding what happened through our quality review process, and trying to make sure it never happens again, so what are the steps that went wrong and how do we improve them."
In addition to the internal review, Alberta Health Services has asked the Health Quality Council of Alberta to also review protocols.
The HQCA review will focus on medication management of total parenteral nutrition in all age groups.
"We have multiple checks and balances. We still do have those checks and balances currently. The review will help ensure really going through all the different steps between the time medication is ordered to the time supplement is given to the patient," Yiu sid.
"But at the end of the day, checks and balances are not invaluable, unfortunately, but we need to make sure it is as rigorous as possible to try prevent these from ever occuring again."
The internal review has already begun and is expected to take about three months.
The province says families affected by the mix-up live all over western Canada.
The majority of those families have already been contacted directly by Alberta Health Services and Convenant Health.
Parents with questions or concerns can call 1-855-550-2555 or complete an online form here.