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Medication errors related to parenteral nutrition: data from a teaching hospital

Investigators at the University of Wisconsin Hospital and Clinics conducted a prospective, observational study to quantify and characterize medication errors associated with the parenteral nutrition process.¹ This 471-bed teaching hospital with a level I trauma center has had a nutritional support team in place since 2001. The team is charged with overseeing the entire parenteral nutrition process including prescribing/ordering, preparation, administration, and monitoring. Clinicians at the hospital use an electronic, web-based reporting system to collect information about errors involving parenteral nutrition. The web-based system classifies parenteral nutrition errors into the following categories:

Errors that occurred over an 18-month period were evaluated.¹ The errors could have involved adult or pediatric patients. Data were collected about any adverse events associated with the error, and errors were classified based on severity. The investigators were also interested in determining whether or not parenteral nutrition errors were more frequent than other medication errors, and to compare their error rate with that of other hospitals. Comparative data were obtained from the University Health Consortium (UHC) member institutions (other academic medical centers).

During the study period, 74 errors (1.6%) were identified out of 4730 parenteral nutrition orders.¹ The majority of errors occurred during transcription (29 [39%] of 74) or administration (26 [35%] of 74). The transcription errors occurred during order entry (pharmacy technician on the units) or reentry into the compounder (pharmacist in the central pharmacy) and included choice of the wrong salt form, incorrect dose of electrolytes, wrong amino acid solution, and omission of a drug. The administration errors included wrong rate of infusion or route of administration, wrong patient, and omission of an in-line filter. The majority of errors (91%) were classified as nonharmful, but 11 (15%) of 74 were considered potentially serious, but did not reach the patient. No errors were associated with death, but 6 (8%) caused or contributed to harm for the patient. Examples of harmful errors included a pump programming error that resulted in hyperglycemia, formula intended for central administration given peripherally, and an infusion of an entire bag over 12 hours instead of 24 hours. The number of errors reported with parenteral nutrition (24%) was higher than the rate reported with high-alert medications at the study site (10.3%). Error rates at the study hospital were similar to those reported by UHC member institutions for high-alert drugs and parenteral nutrition.

In order to address the most common errors with the parenteral nutrition process, the institution implemented a change in order forms and the verification step.¹ The new order forms were designed to allow for an easier transcription, and the pharmacists in the compounding area now receive a copy of the original order to reconcile the data entered into the compounder against what was prescribed. In addition, the pharmacist in the compounding area, the decentralized pharmacist, and the nurse document that they have checked the final product against the original order. To address administration errors, nursing must verify infusion rates of the bag at each shift. In addition, pharmacy technicians verify rates while conducting their daily intravenous (IV) rounds.

A.S.P.E.N. Safe Practices for Parenteral Nutrition
In 2004, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) published a practice guideline describing safe practices for parenteral nutrition.² The document covers various aspects of the parenteral nutrition process, including ordering and administration, the 2 steps associated with the highest frequency of errors in the above study. The recommendations for ordering center around development of a standardized order form and the required components of the form. There is brief mention of computerized prescriber order entry, but at the time of publication, very few institutions were using such technology.

In regards to administration, use of an infusion pump with protection against “free flow” is recommended.² Free flow can be especially dangerous with parenteral nutrition due to dextrose and potassium concentrations. Another recommendation is to confirm the identity of the patient prior to administering the solution in order to ensure that it is given to the correct patient.

Summary
Data from the University of Wisconsin reaffirm that errors occur with parenteral nutrition, notably in the transcription or administration portion of the process. Publication of this study should serve to remind practitioners of the importance of vigilance with the parenteral nutrition process. Although the majority of errors were classified as nonharmful to patients, some were considered “near misses” or were harmful to patients. The A.S.P.E.N. guidelines on safe practices for parenteral nutrition offer suggestions and recommendations that can be implemented in an institution to improve the parenteral nutrition process.

References