Affiliations: [a] Centre for Perinatal Research, Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| [b] Neonatal Unit, Derby Children’s Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| [c] Parent authors, Derby, UK
Correspondence:
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Address for correspondence: Dr Shalini Ojha, Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham. Room 4117, Medical School Building, Royal Derby Hospital, Derby DE22 3NE, UK. Tel.: +44 7469 037398; E-mail: [email protected].
Abstract: BACKGROUND:Intravenous lipid emulsions (ILEs) provide essential fatty acids during parenteral nutrition (PN). Serious adverse events including death can occur from overdose. We report an accidental overdose in a preterm infant. METHOD:On Day 2 of life, a 29-week gestational age (GA) twin was accidentally given 47.5 mL of Intralipid20% (≈3x daily amount) in 50-minutes. RESULTS:No apparent clinical deterioration occurred, although blood samples were lipaemic. Outcomes at 2 years corrected GA were similar to that of his twin. Service changes were made to infusion packaging and administration to avoid similar errors. CONCLUSIONS:Medication errors in neonates are unfortunately common. Published articles usually focus on poor outcomes, which can increase the distress for parents of children where errors have occurred. Publishing the full spectrum of outcomes instead allows parents and professionals to be aware of all possibilities and lessons learnt, even if serious harm was avoided.
