Patient safety alert: Albumin admixture

Dilution of 25% albumin with sterile water for injection to make 5% albumin results in patient injury, including death.

DESCRIPTION OF THE PROBLEM:
The practice of diluting the 25% albumin concentration is a consequence of the continuing albumin shortage. Severe adverse reactions, including fatalities, have been reported to result from using 25% albumin diluted with sterile water for injection to prepare a 5% albumin solution. These errors have occurred primarily when dilution instructions are taken from the outdated 8th Edition of the reference text Trissel's Handbook on Injectable Drugs. Patients have developed fatal hemolysis and/or renal failure when large volumes of hypotonic 5% albumin are infused.

SCOPE and SEVERITY:

NCC Medication Error Index Number of Cases
Category I: An error occurred that resulted in patient death 3
Category E: An error occurred that resulted in the need for treatment or intervention and caused temporary patient harm 1

* National Reporting programs used as a source for this data are the  USP-ISMP Medication Errors Reporting program, the FDA MedWatch  Program, and the JCAHO Sentinel Event Reporting Program.

SUGGESTED ACTIONS:
Health care professionals and health care organizations should consider the following:

  1. Update reference materials in a regular and timely manner.

  2. Discard all outdated reference texts and reference software.

  3. Consult more than one reference when looking up an unfamiliar drug or procedure.

  4. Review appropriate dilution procedures for large volume albumin solutions.

  5. Use alternative crystalloid or colloid solutions when 5% albumin supplies are not available during periods of shortage.

  6. Discourage the preparation of 5% solutions from the 25% solution.

  7. Continue to report errors associated with albumin admixture so that accurate frequency and severity of these errors can be assessed.

Posted: 07/1999