ABSTRACT
During a two-week period in September 1992, eight children died from massive infection after receiving TPN at four different hospitals in Johannesburg, South Africa. The source of this infection was traced to four batches of TPN that had been compounded in flexible film isolators by a private company. The subsequent investigation revealed that, while the equipment and the operating procedures were generally fairly sound, there was a catalogue of minor events of poor operating procedure and QA, such as the failure to clean up fluid spillages. These combined to allow the buildup of high levels of pathogenic organisms in some of the dispensed bags of TPN.
