ABSTRACT
Dr. Rich Molteni, the medical director at Seattle Children’s Hospital, was meeting with the directors of pharmacy and clinical nutrition in his office one morning.
The discussion centered on a recent event that was both seminal and scary. A toddler had received four times the intended dose of potassium in his bag of total parenteral nutrition (TPN). TPN is the nutrient-rich admixture with over 30 additives that is lifesaving in patients unable to eat or be fed through an intestinal feeding tube.
