[ Vol. 13 No. 3 ] (September - December 2012 )
Safe parenteral therapy. The role of the pharmacist. Case studies of where things went wrong.

Patrick A. Ball  Patrick A. Ball
CharlesSturt University (Australia)


When something goes wrong, especially if patients are harmed, the causes must be investigated, and the lessons learned applied to prevent repetition. Parenteral fluid systems are used throughout our hospitals and increasingly in rest homes, palliative care and domiciliary care.

Based upon a series of real cases from the clinical area, the steps required to investigate problems are examined, and the lessons learned presented.

When medications are added to parenteral fluid systems, even in well regulated units that have validated their practices, things can go wrong. Cases will be presented where a very minor change such as a different brand of ‘3-way stopcock connector,’ ‘Y’ connector or extension set turned a formerly safe parenteral fluid pathway into a dangerous one, allowing medications to come together within the fluid pathway leading to chemical reactions and/or precipitation within the fluid pathway. Minor changes can lead to effects such as flow diversion, retrograde flow, pooling in ‘non-circulating fluid spaces’ and other de-separation effects.

These can lead to treatment failure, infusion of large loads of particulate material and altered pharmacokinetics.

Further cases will look at electronic infusion control devices. These have revolutionised practice and imprived safety but have limitations that it is important for health practitioners to understand. Incidents have also arisen in countries within PENSA where it has been decided to use non-specialist service and repair services.

Every medication consists of an active medication a formulated medicinal product with excipients, and a delivery system. It is important for health professionals to understand exactly what is in the products they are using.

Evidence suggests that the problems are far wider than many professionals realise; one of the main reasons for this is that many of the effects cause the patient to look like a sick, intensive care patient. Working together, health professionals can achieve a great deal to ensure that their parenteral fluid systems are safe, effective and are delivering what we believe they are delivering.


The 14th Congress of Parenteral and Enteral Nutrition Society of Asia
“From Nutrition Support to Nutrition Therapy”
October 14-16, 2011, Taipei, Taiwan 
Page: 26