Frequency and Severity of Errors Related to Neonatal and Pediatric Parenteral Nutrition

Purpose: Parenteral nutrition (PN) is a high risk medication with the potential to cause patient harm. Errors may occur during prescription, transcription, compounding, and administration. Since June 2009, our institution has implemented a number of changes including use of a weight-based PN order form, in-house automated PN compounding with age/weight-based templates and institution-specific limits, and an electronic medical record and computerized physician order entry (CPOE). The purpose of this study was to evaluate the incidence, location, type, and severity of errors related to the PN process before and after changes in practice.

Methods: This retrospective review evaluated all PN-associated errors submitted through the internal event reporting system over a 36-month period (July 2008 to July 2011). Data collected included location of the incident, step in the PN process, and error type and severity (defined by the National Coordinating Council for Medication Error Reporting and Prevention).

Results: Ninety-four PN-associated errors were reported during the evaluation period. PN-associated errors, which were primarily administration-related errors, trended downward after implementation of weight-based PN order form and in-house automated compounding and increased after implementation of CPOE, primarily due to increased transcription-related errors. The majority of all errors were determined to be wrong rate and classified as severity categories C and D. None of the errors reported resulted in patient harm.

Conclusions: Implementation of automated compounding software and weight-based PN order forms and limits may potentially minimize PN-associated errors, while CPOE may increase PN-associated errors most likely due to the lack of an interface between CPOE and PN compounding software. By instituting various safeguards throughout the PN process, PN-associated errors may be less likely to cause patient harm. When evaluating PN practices within institutions, the vulnerability of the PN process due to the lack of an interface between CPOE and compounding software should not be underestimated.