AHRQ’s April Issue of Web M&M Examines Factors Leading to Error in Total Parenteral Nutrition
The April issue of AHRQ Web M&M features a Spotlight Case describing how a 3-year-old boy hospitalized with anemia who was receiving chronic total parenteral nutrition (TPN) was given a 10-fold increase in the amount of sodium in the TPN. The error was recognized, corrected, and the boy did not experience any adverse consequences. Upon a formal review of the case, multiple errors led to the excess sodium error, including inaccurate transcription by the pharmacist into the hospital’s computerized provider order entry system and multiple automatic warning systems that were ignored. A commentary on the case is provided by Joseph I. Boullata, Pharm.D., R.Ph., professor of pharmacology and therapeutics at the University of Pennsylvania, Philadelphia. The Perspectives on Safety feature section features an interview with Christopher Landrigan, M.D., associate professor of medicine and pediatrics at Harvard Medical School, Boston, whose research on the effects of sleep deprivation has led to policy changes in resident duty hours and supervision. Physicians and nurses can receive free CME, CEU, or training certification by taking the Spotlight Quiz. Select to read the current issue of AHRQ Web M&M.