Total parenteral nutrition review /

AHS initiated its own internal reviews of the adverse event and requested that the Health Quality Council of Alberta (HQCA) conduct an independent review of all PN processes, pursuant to Section 15(2) of the Health Quality Council of Alberta Act.3 Purpose, objective, and scope The objective of the review was to examine the implications for quality and patient safety with respect to the processes o [...] The current state of the infrastructure at the UAH and RAH limits the possibility of improvements, and a centralized pharmacy for the Edmonton Zone, such as the one in the Calgary Zone, has never reached the approval stage. [...] Enabling actions Improve visual verification and connection to the correct port on the ExactaMix 2400 by increasing the visibility of the port number labelling (i.e., through more effective use of contrast and number placement) and by applying a second label, with the port number, to the end of the tube near the port. [...] The objective of the review was to examine the implications for quality and patient safety with respect to the processes of PN in the Edmonton Zone, and to make recommendations for system‐level improvements (Appendix II). [...] Findings and recommendations from the AHS PN QAR of the adverse event and human factors evaluation The findings and recommendations from the AHS PN QAR were reviewed to gain a better understanding of the background, context, and specific details of the event.