Total Parenteral Nutrition Review
July 23, 2014
The Health Quality Council of Alberta delivered a report to Alberta Health Services (AHS) on June 27, 2014, following their request in May 2013 for the HQCA to conduct an independent review of the implications for quality and patient safety in AHS processes related to all aspects of Total Parenteral Nutrition (TPN) in the Edmonton Zone.
AHS requested the HQCA conduct this review of parenteral nutrition (PN) processes after a calculation error occurred at the University of Alberta Hospital in the creation of a recipe that was used to prepare a nutrient additive, which resulted in 186 neonatal and pediatric patients at three Edmonton hospitals receiving an incorrectly prepared PN admixture between December 13, 2012 and April 12, 2013.
The report contains nine recommendations for AHS.