Medication error is common in hospitalized patients. However, milk ingestion through an intravenous
line is a rare entity that has fatal medical sequel if managed late or misdiagnosed.
A rare case report of an 11 month old infant who received a 5 ml of intravenous formula milk through
central line with subsequent complications of sepsis and acute respiratory distress syndrome within
few minutes of ingestion. Moreover, complications of acute renal failure along with hepatic
insufficiency and coagulation disorders could happen.
These errors are possible due to compatible connections between intravascular catheter and enteral
feeding catheter.
Confusion between lines connected to the patient could occur, either due to system or human errors.
Healthcare system has a major role in elaborating the use of each line connected to the patient whether
to the patient’s family or entitled caregiver to decrease the potential morbidity or mortality of
children.
Author(s): Sulafa Sindi, Morouj Kandil, Mohammed Ghazi
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