MEDICATION ERRORS
Michael R. Cohen ScD, MS, RPH

$3.95
Nursing2014
May 2011 
Volume 41  Number 5
Pages 16 - 16
 
  PDF Version Available!

ABSTRACT
Clinimix E, a parenteral I.V. nutrition solution from Baxter, comes in a multichamber bag-one chamber contains dextrose and calcium, and the other amino acids and electrolytes. A seal between the two chambers must be broken so the contents of the two chambers can mix before administration. (Fat emulsions and additional electrolytes can be added if needed.)A hospitalized patient was prescribed Clinimix E if the patient didn't eat at least 50% of breakfast. The patient ate 50% of breakfast, but the charge nurse wanted to monitor the patient's lunch intake before deciding whether to administer parenteral nutrition. After the pharmacy was closed, two charge nurses signed out a bag of Clinimix E per protocol and administered it. However, the next day another nurse discovered that the seal between the chambers was intact, and only the amino acid and electrolyte chamber had been infused. (The access port for I.V. administration is on the side of the amino acid and electrolyte chamber.) The patient

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