Pharmacist jailed for tech's mistake

[Taurus]

This is why you keep anyone who you are legally liable for on a very short lease.

Former University Hospitals pharmacist sentenced to six months in jail for 2-year-old's death
Posted by Leila Atassi, The Plain Dealer August 14, 2009 10:32AM

CLEVELAND -- The pharmacist found guilty of involuntary manslaughter in the death of a 2-year old girl was sentenced this morning to six months in jail and six months house arrest.

Eric Cropp of Bay Village also must do community service after his jail sentence. Cropp was ordered to seek out professional groups and tell them his story.

Cropp was the supervising pharmacist at Rainbow Babies & Children's Hospital on Feb. 26, 2006, when a pharmacy technician prepared a chemotherapy treatment for 2-year-old Emily Jerry, who was being treated for cancer.

The solution was 23 percent salt when the formula called for a saline base of 1 percent. The child slipped into a coma after receiving the treatment and died on March 1.

As supervising pharmacist, Cropp had the duty of inspecting and approving all work prepared by technicians before it was given to patients.

Cropp was initially charged with reckless homicide but agreed to plead no contest to the lesser charge of involuntary manslaughter.

Emily's mother Kelly Jerry attended the hearing and spoke afterward.

"It will never be over for me and my family," she said. "Mr. Cropp received six months. But six months of his life doesn't compare to what we have to endure for a lifetime."​

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[Passion4Sci]

It's Dr. Cropp, not Mr. Cropp.

Well, maybe not now, LOL.

Sorry, I shouldn't laugh at this, but since we were just discussing w/ Kirbypuff last week about this same very subject, I find this article to be so apropos...

Thanks for the share.

 

[confettiflyer]

Unfortunately, if you jail everyone who has ever made a medical mistake, you'd essentially have jailed every practitioner out there.

The DA and family smelled blood (and money, I'm sure), greedy greedy greedy. There needs to be tort reform and essentially a blanket guarantee that, short of malicious intent on the part of the practitioner, medical mistakes are unactionable.

Total miscarriage/misapplication of justice IMO.

 

[DrWrong]

I'm curious to know two things:

1) What type of cancer did the child have? Was it pretty much a death sentence [Not to sound bad, but I can't think of how else to ask that]

2) What happens in a situation like this? Does the pharmacist lose his license?

 

[cjhrph]

What happens in a situation like this? Does the pharmacist lose his license?

That train already left the station. See page 21....

http://www.google.com/url?sa=t&sour...mtjnDA&usg=AFQjCNFeWnqPh9xV3K_ixguTFmoT_rphrA

 

[Praziquantel86]

Unfortunately, if you jail everyone who has ever made a medical mistake, you'd essentially have jailed every practitioner out there.

The DA and family smelled blood (and money, I'm sure), greedy greedy greedy. There needs to be tort reform and essentially a blanket guarantee that, short of malicious intent on the part of the practitioner, medical mistakes are unactionable.

Total miscarriage/misapplication of justice IMO.

I'll agree with you that there needs to be some serious tort reform (probably one of the most important issues in healthcare right now, and its being completely overlooked), but I don't think limiting it to malicious intent is the right answer.

Cases of gross incompetence, while not intended to do harm, certainly achieves that end. Something that springs to mind is the radiation oncologist performing brachytherapy at the VA, when he was never adequately trained to do so.

On the other hand, if someone is acting to the best of their ability and using current standards of care, they should absolutely be protected from civil liability. Mistakes and negative outcomes happen, and in many cases, there's absolutely nothing to do to prevent it.

 

[confettiflyer]

Cases of gross incompetence, while not intended to do harm, certainly achieves that end. Something that springs to mind is the radiation oncologist performing brachytherapy at the VA, when he was never adequately trained to do so.

Good point, I'll concede that. That case was here at the Philadelphia VA, and, as I recall, records were "scrubbed" of incriminating information taking advantage of a loophole to mask mistakes. My contacts familiar with Penn Faculty (he was an outside contractor, not a VA MD) say he's actually a nice guy, that NYT article was pretty damning.

 

[themorphinerule]

That train already left the station. See page 21....

http://www.google.com/url?sa=t&sour...mtjnDA&usg=AFQjCNFeWnqPh9xV3K_ixguTFmoT_rphrA

So this guy had it coming... apparently he had made ALOT of mistakes for days in a row. I wonder if he was working two jobs. But a lot of misbranding and mislabeling... suppositories directed to be taken orally, ear drops for optical use.. rx for metformin er 500 but given biaxin xl 500... c'mon, those are the basics of doing your job right. Application for license renewal: DENIED. lol

 

[Aznfarmerboi]

So this guy had it coming... apparently he had made ALOT of mistakes for days in a row. I wonder if he was working two jobs. But a lot of misbranding and mislabeling... suppositories directed to be taken orally, ear drops for optical use.. rx for metformin er 500 but given biaxin xl 500... c'mon, those are the basics of doing your job right. Application for license renewal: DENIED. lol

To be fair, misbranding metformin er and biaxin xl happens more than you think. What he did was filled metformin for biaxin and biaxin for metformin. It wasnt so much that the drug was completely wrong but he mixed two rxs that the patient would have gotten anyway.

 

[cjhrph]

To be fair, misbranding metformin er and biaxin xl happens more than you think. What he did was filled metformin for biaxin and biaxin for metformin. It wasnt so much that the drug was completely wrong but he mixed two rxs that the patient would have gotten anyway.

I am sure the guy was a mess after that girl died. Who wouldn't have been? All those errors in the report were made after the "incident. He was obviously in no condition to working the bench. He should have been placed on temporary leave and given some time to get act back together. I feel bad for him..

 

[MountainPharmD]

To be fair, misbranding metformin er and biaxin xl happens more than you think. What he did was filled metformin for biaxin and biaxin for metformin. It wasnt so much that the drug was completely wrong but he mixed two rxs that the patient would have gotten anyway.

It does?

 

[ngduocsi]

Could someone please explain to me how can the concentrated NaCl killed the baby? The mistake was done but how could the baby die from it? The news never explained. I could not find any information about this anywhere or maybe I didn't search hard enough!

 

[StaviZFingerZ]

Could someone please explain to me how can the concentrated NaCl killed the baby? The mistake was done but how could the baby die from it? The news never explained. I could not find any information about this anywhere or maybe I didn't search hard enough!

Is you a pharmacist? Then you know the concept of hypotonic, isotonic, and hypertonic solution? What would you consider the NaCl solution the baby received? Then what would the adverse reaction of the solution?

I haven't read anything about this nor do I know the cause of death. But you should be able to understand the effects of hypertonic solution in peds.

 

[StaviZFingerZ]

Aight, let me be a less of jack ass and throw this out there.

I'll go out on the limb and say it was probably due to lethal hypernatremia. So that should give you some good leads on where to look.

Hypertonic Saline, Lethal Hypernatremia in Peds.... you should be able to find some case studies or articles..

 

[Quiksilver]

the chemo must have ****ed the sodium levels in the body pretty hard.
all the orders that we put in get checked by at least 2 pharmacists and the tech that makes it. I guess sometimes mistakes go through

i just want to know how the solution goes from 1% to 23%? Doesn't anyone think thats an odd amount to be off by, its not a factor of 10 or anything like that? I wonder how big the bag was?

 

[StaviZFingerZ]

the chemo must have ****ed the sodium levels in the body pretty hard.
all the orders that we put in get checked by at least 2 pharmacists and the tech that makes it. I guess sometimes mistakes go through

i just want to know how the solution goes from 1% to 23%? Doesn't anyone think thats an odd amount to be off by, its not a factor of 10 or anything like that? I wonder how big the bag was?

I recall stock concentrated vial of NaCL is 23.1%? Is it? It's been a while since I mixed TPN. Hard to believe they would inject undiluted stock solution of concentrated NaCL..

 

[Quiksilver]

I recall stock concentrated vial of NaCL is 23.1%? Is it? It's been a while since I mixed TPN. Hard to believe they would inject undiluted stock solution of concentrated NaCL..

i believe there is that "must be diluted" **** staring at you when you put your needle into the vial.

maybe this guy sucked in life as far as doing dilutions

 

[Aznfarmerboi]

It does?

yes especially if they dont have computer verification systems like CVS or Walgreens. I have worked in independents where they dont have a scanning system so they put the drugs out with the label, you look inside and match it to bottle. If the person is a family; their medications are bunched together and there are a lot of distractions, this can happen.

Either way, this guy should retire...

 

[Vyvanase]

Wow I wonder what kind of place he even worked at. Did the hospital even have a set of standards to make drugs for peds. For the little ones at my hospital, we try to throw all IVs in D5W if it is stable to reduce errors. NS is just bad for the babies. In chemo, we have specific ways to make chemo and do not stray. Also, that place should have their best techs in the most critical areas (peds/chemo) for mistakes. In peds, we do tend to use the highly concentrated electrolytes to reduce volume and everything is thrown into a syringe, but still a straight up NS vial is a Big red flag with an injection cap on it.

 

[ngduocsi]

In a hypernatremic situation, water leaves the intracellular space to correct the osmotic difference between the intracellular and extracellular compartments. This results in cellular shrinkage and crenation. Due to fine vascular attachments to the calvarium, the brain is most vulnerable to shrinkage. Brain shrinkage can lead to subarachnoid and subcortical hemorrhages, vascular rupture with cerebral bleeding, subdural hematomas, venous thrombosis, infarction of the cerebral vessels, permanent neurologic damage, and death.
OK, I got the answer, thanks for the info and the sarcasm!
Mistake was done but then these kind of mistakes (colorless solution) are so easy to make if you aren't careful and there is only so much you can be careful about.

 

[Rhue]

Are all of us pharmacists going to thrown into jail everytime a patient is killed? What if it is the combined fault of the MD and the pharmacist?

Will this be an isolated case or will it have vast ramifications for the field of pharmacy? Will other healthcare providers also be affected?

Medical malpractice is already one of the leading causes of death in this country. This could be very scary news for those practicing in pharmacy.

 

[WhiteSnows]

This make me want to do nuclear pharmacy instead of clinical pharmacy.

 

[Farmercyst]

I wonder if they check all stock bottles and syringes when chekcing chemos. I know they did religiously when we did abx bags. Though I've been told the practice is not universal.

 

[AdamSanders]

After this case I believe the "Emily Act" was passed in Ohio. This made it hell for me to get any type of retail volunteer work. When I did find a pharmacy that would let me shadow I found out that that the pharmacist I shadowed's roommate replaced this pharmacist at the hospital. I believe the tech responsible quit or was fired as well.

 

[MountainPharmD]

This make me want to do nuclear pharmacy instead of clinical pharmacy.

So you think mistakes can't happen in nuclear pharmacy?

 

[MountainPharmD]

This guy is a disaster. It is a wonder he only killed one person.

FINDINGS OF FACT
1. Received an order for etoposide (with a base solution of 0.9% sodium chloride), he dispensed etoposide having been compounded with a base solution of 23.4% sodium chloride, which had not been specifically prescribed by the physician. The two-year-old patient subsequently died.

2. when adding a drug to a parenteral solution, fail to properly label the admixture with the correct name and amount of the parenteral solution, to wit: when compounding the preparation, failed to affix a distinctive label to the preparation indicating the name of the solution that was actually used.

3.Compazine 10 mg tablets, #60, with directions for use as: "Take one tablet by mouth every 4 hours as needed for nausea and vomiting," he dispensed prochlorperazine 10 mg tablets, with the directions "… as needed for pain." The label did not indicate the correct directions for use as prescribed.

4. Vicoprofen, #40, he dispensed tramadol with acetaminophen, which had not been specifically prescribed by the physician. Biaxin XL 500 mg
tablets, #20, he dispensed metformin ER 500 mg tablets, which had not
been specifically prescribed by the physician.

5. Glucophage XR 500 mg (metformin), #30, he dispensed Biaxin XL 500 mg tablets, which had not been specifically prescribed by the physician.

6. Phenergan 25 mg suppositories, #10, with directions for use as: "Insert one suppository rectally every 8 hours as needed for nausea and vomiting," he indicated the directions for use on the label as: to be taken by mouth.

7. A prescription for Focalin XR 5mg capsules, #30, he dispensed 30 Adderall XR 5 mg capsules, which had not been specifically prescribed by the physician. The 8 year-old patient was harmed.

8. Salsalate 500 mg, he dispensed Sulfasalazine 500 mg #60, which had not been specifically prescribed by the physician.

9. Plendil 2.5 mg tablets, he labeled and dispensed the vial for the wrong patient.

10. VoSol HC, which had been prescribed by an ear, nose, and throat specialist for use in the patient's ear, he labeled the prescription for use "in the eye."

11. Zoloft (sertraline) 100 mg #60 tablets, to be taken: "two tablets every evening, he labeled the prescription as: "Take one tablet twice daily."

12. Avelox 400 mg #7, take one daily, he labeled and dispensed the vial for the wrong patient.

13. Zoloft (sertraline) 100mg, he dispensed sertraline 50 mg tablets, which had not been specifically prescribed by the physician.

14. E.E.S. 200 mg/5ml suspension (erythromycin ethylsuccinate), he dispensed erythromycin with sulfisoxazole suspension, which had not been specifically prescribed by the physician.

15. 2 boxes of Imitrex 6mg/0.5 ml, he dispensed a quantity less than what was indicated on the label.

Does anyone seriously feel sorry for this guy? He should not have been in a position to make the error that killed the 2 year old patient. His chain of command in the hospital failed to properly supervise and train him. He should have been written up and fired long before things got this far.

If I were the family I would sue the hospital and everyone in his chain of command for failure to supervise and monitor. I blame the system for this error.

 

[ForcedEntry]

I would like to know the time span of these events. Was it over the course of a year or a lifetime?

 

[WhiteSnows]

So you think mistakes can't happen in nuclear pharmacy?

I have not heard anyone who died in nuclear pharmacy so far.

 

[diastole]

I would like to know the time span of these events. Was it over the course of a year or a lifetime?

It was over a year after the incident where the child died. The pharmacist admitted that he was not emotionally able to practice anymore. Perhaps all the mistakes came because he was messed up in the head after the little girl died? They didn't present any evidence that he made errors before the girl died so I wonder.

 

[AwesomeGator]

On the other hand...if he admitted that he wasn't emotionally able to practice anymore, then why did he continue to practice? I understand the reason those mistakes may have happened, but theres a huge difference between a reason and an excuse....

 

[ForcedEntry]

I'm sure a little denial was involved...along with anger, bargaining, depression, and acceptance.

.

 

[Sparda29]

They should have seen the mistake coming, but really, the lawsuits filed in this country are out of control.

 

[geekgolightly]

http://www.ismp.org/pressroom/injustice-jailtime-for-pharmacist.asp

An injustice has been done: Jail time given to pharmacist who made an erroR

Posted August 21, 2009

Since Friday’s sentencing of Eric Cropp, an Ohio hospital pharmacist involved in a tragic medication error, staff at the Institute for Safe Medication Practices (ISMP) have been deeply saddened and greatly troubled to learn that he received 6 months in jail, 6 months home confinement with an electronic sensor locked to his ankle after his release, 3 years probation, 400 hours of community service, a fine of $5,000, and payment of court costs. Eric made a human error that could have been made by others in healthcare given the inherent weaknesses in our manual checking systems: he failed to recognize that a pharmacy technician he was supervising had made a chemotherapy solution with far too much sodium chloride in it. The final solution was supposed to contain 0.9% sodium chloride but it was over 20%.

As the president of ISMP, I have not been able to stop thinking about Eric’s situation. I care about the injustice that happened to him because I have spent my entire career spanning more than 30 years trying to help others understand and prevent medication errors. I have never met Eric, but I am familiar with many (certainly not all) of the underlying conditions that contributed to the error. Some details have been provided in the local and national news media; however, I also have reviewed records stemming from Ohio State Board of Pharmacy hearings. I have heard firsthand accounts from others, including a pharmacist who attended a hearing and listened to testimony about the event at the Ohio State Board of Pharmacy, which permanently revoked Eric’s license. I also have been in contact with Eric’s attorneys, Richard Lillie and Gretchen Holderman of Lillie & Holderman, who suggested that I write a letter to the Honorable Judge Brian J. Corrigan in the Cuyahoga County Court of Common Pleas in Cleveland, OH, in support of leniency and avoidance of imprisonment. The letter can be found here. Regrettably, the judge appears to have given my letter little regard, and it likely had little impact on the outcome of the legal proceedings.

 

[jyw003]

I wonder in all the years he's practiced, how come there was all of the sudden an error this big? Maybe he had some emotional set backs that were not supposed to be mixed into work?

 

[HaloKing]

i screwed up the other day... i was pretty torn up about it.. i sent a dose of cefazolin to the ER for a pt when they were already transferred to the floor... haha.. i guess this puts it into perspective.

 

[museabuse]

This guy is a disaster. It is a wonder he only killed one person.



Does anyone seriously feel sorry for this guy? He should not have been in a position to make the error that killed the 2 year old patient. His chain of command in the hospital failed to properly supervise and train him. He should have been written up and fired long before things got this far.

If I were the family I would sue the hospital and everyone in his chain of command for failure to supervise and monitor. I blame the system for this error.

I wonder how all these errors were documented. It sounds like after hospital error he went to independent pharmacy and made tons of errors. who ever was typing up those rxs should not be typing. I can't believe how many errors, even if I didn't verify any rxs and let everything go through I wouldn't make that many mistakes. It almosts seems like someone at the pharmacy was setting him up for failure and documenting the failures he missed. Or he had to be really mentally not right to let that many errors slip by, because if that is what was documented there were probably more un documented.

 

[tackett26]

This is why you keep anyone who you are legally liable for on a very short lease.

Former University Hospitals pharmacist sentenced to six months in jail for 2-year-old's death
Posted by Leila Atassi, The Plain Dealer August 14, 2009 10:32AM

CLEVELAND -- The pharmacist found guilty of involuntary manslaughter in the death of a 2-year old girl was sentenced this morning to six months in jail and six months house arrest.

Eric Cropp of Bay Village also must do community service after his jail sentence. Cropp was ordered to seek out professional groups and tell them his story.

Cropp was the supervising pharmacist at Rainbow Babies & Children's Hospital on Feb. 26, 2006, when a pharmacy technician prepared a chemotherapy treatment for 2-year-old Emily Jerry, who was being treated for cancer.

The solution was 23 percent salt when the formula called for a saline base of 1 percent. The child slipped into a coma after receiving the treatment and died on March 1.

As supervising pharmacist, Cropp had the duty of inspecting and approving all work prepared by technicians before it was given to patients.

Cropp was initially charged with reckless homicide but agreed to plead no contest to the lesser charge of involuntary manslaughter.

Emily's mother Kelly Jerry attended the hearing and spoke afterward.

"It will never be over for me and my family," she said. "Mr. Cropp received six months. But six months of his life doesn't compare to what we have to endure for a lifetime."​

Based on appearance alone normal saline (actually closer to 0.9% than 1%) looks the same is 25% saline... How exactly was this guy supposed to effectively do QC on this? I mean I guess he could have the tech report all calculations and everything he weighed out etc....

Or maybe compounding such solutions should be a soul responsibility of the pharmacist.

 

[tackett26]

This is why you keep anyone who you are legally liable for on a very short lease.

Former University Hospitals pharmacist sentenced to six months in jail for 2-year-old's death
Posted by Leila Atassi, The Plain Dealer August 14, 2009 10:32AM

CLEVELAND -- The pharmacist found guilty of involuntary manslaughter in the death of a 2-year old girl was sentenced this morning to six months in jail and six months house arrest.

Eric Cropp of Bay Village also must do community service after his jail sentence. Cropp was ordered to seek out professional groups and tell them his story.

Cropp was the supervising pharmacist at Rainbow Babies & Children's Hospital on Feb. 26, 2006, when a pharmacy technician prepared a chemotherapy treatment for 2-year-old Emily Jerry, who was being treated for cancer.

The solution was 23 percent salt when the formula called for a saline base of 1 percent. The child slipped into a coma after receiving the treatment and died on March 1.

As supervising pharmacist, Cropp had the duty of inspecting and approving all work prepared by technicians before it was given to patients.

Cropp was initially charged with reckless homicide but agreed to plead no contest to the lesser charge of involuntary manslaughter.

Emily's mother Kelly Jerry attended the hearing and spoke afterward.

"It will never be over for me and my family," she said. "Mr. Cropp received six months. But six months of his life doesn't compare to what we have to endure for a lifetime."​

Based on appearance alone normal saline (actually closer to 0.9% than 1%) looks the same is 25% saline... How exactly was this guy supposed to effectively do QC on this? I mean I guess he could have the tech report all calculations and everything he weighed out etc....

Or maybe compounding such solutions should be a sole responsibility of the pharmacist.

 

[Caverject]

This guy is a disaster. It is a wonder he only killed one person.



Does anyone seriously feel sorry for this guy? He should not have been in a position to make the error that killed the 2 year old patient. His chain of command in the hospital failed to properly supervise and train him. He should have been written up and fired long before things got this far.

If I were the family I would sue the hospital and everyone in his chain of command for failure to supervise and monitor. I blame the system for this error.

I listened to ISMP's webinar today on this subject. Out of those 12 errors you pointed out, 10 were near misses that were caught and documented for cqi purposes...

 

[hornblower]

Given the mushrooming of pharmacy colleges in the last five years, we need to find a way of lowering supply.

I welcome the permanent banishment of incompetent pharmacists.

 

[Ackj]

First off, whats with the metformin/biaxin switch? I'm not practicing, but I can't really see giving diabetics some abx for fun, and I'm not seeing a name similarity either.


Second point to note, I just went to a med error CE this morning, which talked about presumed error rates being about 3/1000, with 600 near misses per fatality or severe permanent injury. This is ridiculously high, especially with 500 scripts/day being fairly common in retail, and more than that for even smaller inpatient hospitals.

 

[Rebel78]

I recall stock concentrated vial of NaCL is 23.1%? Is it? It's been a while since I mixed TPN. Hard to believe they would inject undiluted stock solution of concentrated NaCL..

I was wondering that myself. I haven't mixed chemo (other than MTX ) in about 5 years, so maybe I'm missing something. I don't understand how it happened.

Only TPN I've made either came out of a machine, or a bag of Clinimix.

 

[Caverject]

First off, whats with the metformin/biaxin switch? I'm not practicing, but I can't really see giving diabetics some abx for fun, and I'm not seeing a name similarity either.


Second point to note, I just went to a med error CE this morning, which talked about presumed error rates being about 3/1000, with 600 near misses per fatality or severe permanent injury. This is ridiculously high, especially with 500 scripts/day being fairly common in retail, and more than that for even smaller inpatient hospitals.

the patient was suppose to get biaxin and metformin. The labels were just put on the wrong bottles.

 

[jonniii]

Could someone please explain to me how can the concentrated NaCl killed the baby? The mistake was done but how could the baby die from it? The news never explained. I could not find any information about this anywhere or maybe I didn't search hard enough!

Typically 23.4% saline or supersalt is used if intracranial pressure (icp) is greater than 15mmHg WITH an ICP monitor; sometimes it is also used in symptomatic hyponatremia.

A few complications of using supersalt include:
1) Administration of supersalt requires a central line and rapid infusion (or correcting hypoNa+ too fast) can cause osmotic demyelination syndrome, which is an irreversible neuro disease.
2) Lyte imbalances: hypokalemia, hyperchloremia, hypernatremia
3) Phlebitis if without a central line
4) heart failure (fluid overload with volume expansion)

Just a few thoughts with this mistake:
1)When a RPh sees an order for 1% saline...shouldn't he recommend just using 0.9NS? In order to prevent IV mistake as 0.9 is commercially available?
2)If he sees 23.4% made by a tech, he should have at least called the nurse to make sure the pt's chem-7 and ICP are monitored before the bag reaches the nurse's hand.
3)I assume 1000ml is made; is supersalt ever given 'continuously' in kids?? Not in adults...in adults even scheduled dosing is not encouraged.
--> looks like this error could have prevented with a phone call to the unit.

 

[njac]

Typically 23.4% saline or supersalt is used if intracranial pressure (icp) is greater than 15mmHg WITH an ICP monitor; sometimes it is also used in symptomatic hyponatremia.

A few complications of using supersalt include:
1) Administration of supersalt requires a central line and rapid infusion (or correcting hypoNa+ too fast) can cause osmotic demyelination syndrome, which is an irreversible neuro disease.
2) Lyte imbalances: hypokalemia, hyperchloremia, hypernatremia
3) Phlebitis if without a central line
4) heart failure (fluid overload with volume expansion)

Just a few thoughts with this mistake:
1)When a RPh sees an order for 1% saline...shouldn't he recommend just using 0.9NS? In order to prevent IV mistake as 0.9 is commercially available?
2)If he sees 23.4% made by a tech, he should have at least called the nurse to make sure the pt's chem-7 and ICP are monitored before the bag reaches the nurse's hand.
3)I assume 1000ml is made; is supersalt ever given 'continuously' in kids?? Not in adults...in adults even scheduled dosing is not encouraged.
--> looks like this error could have prevented with a phone call to the unit.

do you ever actually use NaCl 23.4%? I've seen 3% and 5% for IV use for head injuries, and 7% and 10% for inhalation in CFers, but never actually 23.4% anywhere outside of the TPN hood.

 

[jonniii]

do you ever actually use NaCl 23.4%? I've seen 3% and 5% for IV use for head injuries, and 7% and 10% for inhalation in CFers, but never actually 23.4% anywhere outside of the TPN hood.

Yes. Usually for high icp. 23.4% 15ml x1.

 

[WVUPharm2007]

do you ever actually use NaCl 23.4%? I've seen 3% and 5% for IV use for head injuries, and 7% and 10% for inhalation in CFers, but never actually 23.4% anywhere outside of the TPN hood.

You'll see dialysis nurses use the stuff occasionally, too.