It was reported that the display of an exactamix automated compounding device had misused lipid products.Customer stated "the compounder had been set up incorrectly and their technicians applied the smof lipid barcode labels to their intralipid containers.This caused the compounder to deliver intralipid in place of smof lipid during formula runs".The issue had occurred during compounding; however, it was reported there was patient involvement.Therefore, the bag was infused to a patient.There was no patient injury or medical intervention associated with this event.No additional information is available.
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Additional information: it was reported the customer misused the lipid products by setting up the device incorrectly.The technicians applied the smof lipid barcode labels to their intralipid containers.Use errors and proper user instructions are addressed in ¿extamix operator manual¿, which is included with every extamix device.The guide instructs the user to make sure the user labels the inlet with the appropriate, numbered bar code label that was packaged with the valve set.It also tells the user to check that the correct inlet is attached to the correct ingredient and port, as well as, labeled with the correct bar code label.A review of the label for the product family will be conducted.Should additional relevant information become available, a supplemental report will be submitted.
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