(b)(6) pts (26 pediatric, 21 adult) received x 4 magnesium sulfate doses compounded in their tpn because of a new diluted magnesium sulfate file added to our baxter abacus tpn software unintended to go live but was created for initial testing.The diluted file was created on (b)(6), and the compound used that file for 24 hr tpn bags pumped on (b)(6) resulting in x 4 doses above orders.The software allowed the same ndc to be entered for the current mag sulfate file as well as the new diluted mag sulfate file.The software also defaults to have the "unavailable" option box unchecked.The pharmacist adding the new file did not realize that this boxed needed to be checked to prevent the file from potentially going live.We in contact with baxter regarding the event.We have also contacted (b)(4) to report the event and forwarded software screenshots.
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