%0 Case Reports
%T Home Parenteral Nutrition and Intravenous Fluid Errors Discovered Through Novel Clinical Practice of Reconciling Compounding Records: A Case Series.
%A Murphy MK
%A Gura KM
%A Tascione C
%A Carey AN
%A Duggan CP
%A Raphael BP
%J Nutr Clin Pract
%V 32
%N 6
%D Dec 2017
%M 28850287
%F 3.204
%R 10.1177/0884533617722759
%X Home parenteral nutrition (HPN) and home intravenous (IV) hydration are complex, high-risk life-sustaining therapies for children and adults with severe digestive disorders. HPN compounding errors have the potential to cause serious patient harm. Here we present a retrospective case series at an interdisciplinary pediatric HPN program that includes specialized pharmacists reconciling prescriptions against commercial compounding records. Seven HPN or IV hydration patients were affected by significant errors in anion balance, copper, potassium, sodium, and infusion volume. Outpatient pharmacists' or other clinicians' review of compounding records as part of routine quality assurance process is critical for identifying and preventing errors.