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An order was placed for compounded sodium chloride 0.22% for enteral use for an   infant. Pharmacist Sara Frey, recognizing the gravity of providing hypertonic saline to an infant who does not require it—including major fluid shifts and brain side effects—performed her own time-out after the solution was compounded and scanned appropriately. Upon visual inspection, she realized that the dispense prep computer program had a malfunction which allowed incorrect components to be barcode scanned without an error alert—and the order had been prepared using 23% sodium chloride instead of 0.22% sodium chloride. Had this solution reached the patient it would have barcode scanned for Nursing without error and could have resulted in serious harm to the patient. The dispense prep system was fixed so that this error does not occur again.​

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