Original Article

Pediatric Nephrology

, Volume 21, Issue 6, pp 842-845

First online:

Medication errors and patient complications with continuous renal replacement therapy

  • Jeffrey F. BarlettaAffiliated withDepartment of Pharmacy, Spectrum Health Email author 
  • , Gina-Marie BarlettaAffiliated withPediatric Nephrology & Transplantation, DeVos Children’s Hospital
  • , Patrick D. BrophyAffiliated withPediatric Nephrology, University of Michigan
  • , Norma J. MaxvoldAffiliated withPediatric Critical Care, DeVos Children’s Hospital
  • , Richard M. HackbarthAffiliated withPediatric Critical Care, DeVos Children’s Hospital
  • , Timothy E. BunchmanAffiliated withPediatric Nephrology & Transplantation, DeVos Children’s Hospital

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Continuous renal replacement therapy (CRRT) is commonly used for renal support in the intensive care unit. While the risk of medication errors in the intensive care unit has been described, errors related specifically to CRRT are unknown. The purpose of this study is to characterize medication errors related to CRRT and compare medication errors that occur with manually compounded solutions versus commercially available solutions. We surveyed three separate internet-based, pediatric list serves that are commonly used for communications for programs utilizing CRRT. Data regarding CRRT practices and medication errors were recorded. Medication errors were graded for degree of severity and compared between programs using manually compounded dialysis solutions versus commercially available dialysis solutions. In a survey with 31 program responses, 18 reported medication errors. Two of the 18 were related to heparin compounding, while 16/18 were due to solution compounding errors. Half of the medication errors were classified as causing harm, two of which were fatal. All medication errors were reported by programs that manually compounded their dialysis solutions. Medication errors related to CRRT are associated with a high degree of severity, including death. Industry-based, commercially available solutions can decrease the occurrence of medication errors due to CRRT.


Medication errors Continuous Dialysis Dialysis solutions