Nearly 200 babies and children were given incorrectly mixed supplements

EDMONTON – Alberta Health Services (AHS) has asked for a review after 186 neonatal and pediatric patients received incorrectly mixed nutritional supplements.

On Friday, AHS revealed it has asked the Health Quality Council of Alberta (HQCA) to review protocols and procedures for the preparation of the Total Parenteral Nutrition supplement.

AHS says a calculation error occurred during the preparation of the supplement.

“We are deeply sorry for the concern this error has caused to families and patients,” said Dr. Verna Yiu, Executive Vice President and Chief Medical Officer, Quality and Medical Affairs. “I want to stress that there have been no deaths, illnesses or injuries as a result of this error.”

“The risk of any babies or children developing complications as a result of this error is extremely low.”

“We’ve done a very extensive literature review, and we don’t feel that there’s actually any chance of complications, because none of them received a dose that was over the maximum recommended levels,” clarified Yiu.

Officials say there is no evidence of adverse medical effects for those who received the supplement. The incorrectly mixed product contained trace mineral elements at a dose that was still less than the maximum recommended doses for each element, AHS says.

“None of the patients received doses that were above the recommended maximum levels,” said Yiu.

The supplement was prepared at the University of Alberta hospital pharmacy and was given to patients at that hospital, the Grey Nuns hospital, and the Misericordia community hospital between December 2012 and April 2013.

“It was a three and half month period where we were following that recipe,” said Dr. Ernest Phillipos, Regional Medical Director, Neonatal Intensive Care.

Nearly all of the families of the patients affected have been notified by AHS and Covenant Health. Officials are contacting the remaining families affected.

Parents with questions or concerns can contact AHS Patient Relations through its toll-free number, 1-855-550-2555, or complete a Patient Relations online feedback form at www.albertahealthservices.ca/273.asp

“Our neonatal intensive care and pediatric units are among the best in the country caring for sick babies from Western Canada and the Northwest Territories,” said Phillipos. “These units are and continue to be safe places for babies and children to receive the care they need.”

In a news release, AHS explained that Total Parenteral Nutrition (TPN) is used for premature babies, children and adults who are ill and cannot receive adequate nutrition in any other way. Trace elements containing zinc, selenium, copper and chromium are prepared by mixing the individual components according to a standardized recipe.  These trace elements are often required for premature babies to encourage normal growth and development.

The calculation error resulted in two times the prescribed dose of each component being mixed into the supplement. Each patient’s TPN is ordered by dietitians specializing in this area and monitored by specialized physicians.

Yiu said the HQCA review will focus on the medication management of TPN in all age groups in acute and critical care settings in Edmonton.

An AHS internal quality assurance review has already begun.

“In the interim, we have intervened, and we’re starting to double check, review all our master recipes, triple check, just to make sure that currently, we’re doing everything we can to be safe and provide quality care,” said Phillipos.

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