Intravenous Milk Infusion; Rare Medication Error

We report a rare medication error, and its management of a preterm female baby who accidently received formula milk intravenously over two hours through central catheter. She developed leukocytosis, thrombocytopenia, transient metabolic acidosis, superficial thrombophlebitis and thrombosis of greater saphenous vein. She received supportive care with observation of her vital signs, including arterial blood pressure; broad-spectrum antibiotics were given for seven days after the event and low molecular weight heparin. Staff nurse responsibility for initiating the error was addressed by the hospital administration. However; because of most errors are the results of faulty system not faulty people, health care organizations should establish safer environments by using methods to prevent similar errors, also more education for medical staff about medical errors and choosing the most qualified nurses for critical units will decrease the incidence of these errors.