Anything with the letters…”IV” catches my attention immediately then I’m all over the article/topic or whatever the letters are attached to. More so when the word…”CONTAMINATED” appears before it. CONTAMINATED IVs…ugh, not something an infusion nurse want to see or hear at anytime. My heart broke when I saw the news about the 9 patient deaths and 10 sickened after infusion of contaminated IVs in a Alabama hospital. Click here for the news article…
There are many speculations about what exactly caused the patient deaths. But what’s known is there is a link to the TPN (Total Parenteral Nutrition) solutions received by the patients, contaminated with serratia marcescens and were compounded by one specific outside compounding pharmacy. Yes, the TPN solution was not mixed in the hospital pharmacy, it was mixed by another pharmacy. This practice isn’t totally unknown. Many hospitals do contract out their large volume parenteral solution compounding. It is my assumption that when contracts like this exist, there are some QA control somewhere and someone is accountable for the products. What happened and most importantly, how can this happen? There are strict pharmacy guidelines/ USP 797 for compounding and yet we hear about unfortunate incidents like this. Although the patients involved have co-morbidities that may have contributed to the deaths, infusing an IV solution contaminated with serratia marcescens will definitely cause problems.
So what about the nurse/nurses who administered the contaminated IV fluids to the patients? Did they know the TPN solutions were contaminated? No nurse would knowingly administer a contaminated IV solution to a patient. We all vowed to do no harm and protect the safety of our patients. Unless there are obvious signs, labels, or discoloration of the solution, there is no way the nurse would know that the IV solution he/she is about to hang is contaminated. You can’t so you have to trust the pharmacy. The trust relationship we have with our pharmacy colleagues is highly valued that one would never doubt that what’s in the IV bag is the right medication and that IV solutions are sterile and compounded according to standards. Let’s’ hope this incident becomes a learning experience to improve safety and not break that professional trust.
My thoughts and prayers are with the patients and their families and the professionals involved in this unfortunate incident.