Quality assurance review of the three medication and one expressed breast milk incidents at the Alberta Children's Hospital, Calgary, Alberta

Information from the individual interviews was used to flesh out the facts of the incident which were known at the commencement of the review. [...] The need for confidentiality of some of the information and respect for the individuals involved in the incident, as appropriate within a just and trusting culture, are acknowledged, but the organization is encouraged to find a way to share enough information to “tell the story” with a focus on systems connecting the recommendations to prevention of recurrence of adverse events. [...] AHS – Edmonton and the Edmonton hospital worked with the Foothills Hospital in Calgary, the site of the Neonatal Intensive Care Unit in Calgary to develop immediate and longer range recommendations to prevent recurrence of such an event but the information was not shared with ACH at the time. [...] Failure to Check the Line Back to Source in Order Not to Wake the Patient The patient was familiar to the staff as was the family’s desire to avoid any unnecessary wakening of the child. [...] The procedure requires a health care worker to read the order, ensure appropriate drug for the indication, do calculations for the correct dose, select the medication and the dose for administration.