What safety strategies have people employed to prevent tubing mixup for TPN compounders? See brief description of our event below.

The TPN compounder (Baxter ExactaMix 2400) was set up on 1/30/19 afternoon (end of work day) to make a late add on TPN for XXXX. The tubing for Potassium Acetate and Sodium Phosphate were interchanged in the pumping channels (# 5 and #6 ports) and went unrecognized for about 22 hours. The error was discovered when an AIR IN LINE alert fired because one of the vials had run dry. The only patient exposed to the error was Baby XXX XXXX. She received approximately 3 times the amount of intended NaPhos and less K acetate than intended; the clinical impact on the baby was minimal. It resulted in an extra lab draw and omission of IV nutrition for a period of time.