ISMP Canada Safety Bulletin


Volume 18 | Issue 1 | January 4, 2018

Death Associated with an IV Compounding Error and Management of Care in a Naturopathic Centre

Patients with a diagnosis of cancer may choose to use complementary and alternative medicine, such as naturopathy, to support conventional medical therapies (e.g., surgery, chemotherapy).1 The complementary and alternative medicine treatment plan is usually prescribed by a naturopathic doctor and carried out in a complementary care centre (CCC). As part of an ongoing collaboration with a provincial death investigation service, ISMP Canada received a report about the death of an individual who had received, by intravenous (IV) administration at a CCC, a tissue- and wound-healing formulation containing selenium at a much higher concentration than intended. This bulletin highlights some contributing factors identified in the incident analysis, and provides recommendations to prevent similar incidents in the future.

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