AHS Continues to Improve Supplement Safety

HQCA review helps guide ongoing quality and safety improvements

EDMONTON – Alberta Health Services (AHS) continues to improve the quality and safety of the preparation of a nutritional supplement called total parenteral nutrition (TPN).

In April 2013, AHS asked the Health Quality Council of Alberta (HQCA) to review protocols and processes for the preparation of TPN in the Edmonton Zone, following a calculation error that resulted in 186 neonatal and pediatric patients receiving incorrectly mixed supplement.

The supplement contained trace mineral elements at a dose that were double what they should have been, but still less than the maximum recommended doses for each element. There has been no evidence of adverse medical effects for those who received the supplement.

AHS accepts the findings of the HQCA review, released today, and has already made significant progress on many of the recommendations which were also identified as areas of improvement from an internal AHS quality assurance review. These actions include:

  • A redesign of the supplement recipe instruction sheet has taken place to prevent future adverse events. Pharmacy staff have been educated and trained on the new process.
  • An additional independent double-check process has been added to ensure that any recipe changes are correct and have been verified. This will be developed further and rolled out provincially.
  • AHS is in the process of updating guidelines for prescribing parenteral nutrition for newborns, and will implement the updated guidelines provincially.

“Any changes that can improve patient safety will be made. That is why we asked for this review – to ensure that we do not miss any opportunities for improvement. This report has validated our own internal review findings and has reassured us that we are moving in the right direction for making improvements,” said Dr. Verna Yiu, Vice President, Quality and Chief Medical Officer for AHS. “It’s important to remember that there is no evidence that any patient suffered adverse medical effects, but we still take any adverse event very seriously and acted immediately to ensure that our patients receive quality care.

“Albertans should have complete confidence in the work our pharmacists do each day. They play a vital role in our health care system, and their processes are comprehensive and thorough,” said Dr. Yiu. “In addition, our neonatal intensive care and pediatric units are among the best in the country and continue to be safe places for babies and children to receive high-quality, safe care.”

“Alberta Health Services took the right step by requesting an independent quality assurance review and we commend them for their efforts to learn how they can improve,” said Patricia Pelton, Acting Chief Executive Officer, HQCA.

“The HQCA undertook an extensive analysis into the procedures and practices behind this complex process and provided nine recommendations to AHS, which if implemented, will improve quality and safety for this vulnerable patient population.”

The HQCA report is posted online at www.hqca.ca/studies-and-reviews/quality-safety-reviews/completed-reviews/ .

Alberta Health Services is the provincial health authority responsible for planning and delivering health supports and services for more than four million adults and children living in Alberta. Its mission is to provide a patient-focused, quality health system that is accessible and sustainable for all Albertans.