Incidence and Severity of Prescribing Errors in Parenteral Nutrition for Pediatric Inpatients at a Neonatal and Pediatric Intensive Care Unit

Safe and efficient practice of parenteral nutrition in neonates and children aged 0-18 years - The role of licensed multi-chamber bags

Parenteral nutrition (PN) is recognized as a complex high-risk therapy. Its practice is highly variable and frequently suboptimal in pediatric patients. Optimizing care requires evidence, consensus-based guidelines, audits of practice, and standardized strategies. Several pediatric scientific organizations, expert panels, and authorities have recently recommended that standardized PN should generally be used over individualized PN in the majority of pediatric patients including very low birth weight premature infants. In addition, PN admixtures produced and validated by a suitably qualified institution are recommended over locally produced PN. Licensed multi chamber bags are standardized PN bags that comply with Good Manufacturing Practice and high-quality standards for the finished product in the frame of their full manufacturing license. The purpose of this article is to review the practical aspects of PN and the evidence for using such multi-chamber bags in pediatric patients. It highlights the safety characteristics and the limitations of the different PN practices and provides some guidance for ensuring safe and efficient therapy in pediatric patients.

Impact of pharmaceutical validation on prescribing errors in a neonatal intensive care unit. Randomised and controlled study

Purpose

To compare the frequency of electronic prescription errors when the prescription was validated by the clinical pharmacist vs. when it was not.

Methods

This prospective randomised controlled study was conducted in three phases. A randomised phase, in which patients were divided into control and intervention groups, and a pre- and post-intervention phase were consecutively performed to analyse the impact of pharmaceutical validation of prescriptions in a neonatal intensive care unit (NICU). This study was performed at a highly complex NICU at a tertiary hospital. All patients born during the study period who were admitted to the NICU, with a stay lasting ≥24 h, and received active pharmacological treatment were included in the study. Pharmaceutical validation was performed according to the paediatric pharmaceutical care model. A high level of validation was selected for this study. In the intervention group, discrepancies found during the review process were communicated to the medical team responsible for the patients and resolved on the same day.

Results

In total, 240 patients were included in this study. Sixty-two patients were allocated to the pre-intervention (n = 38) or post-intervention (n = 24) groups, and 178 patients were randomly sorted into two groups, control (n = 82 newborns) and intervention (n = 96 newborns). During the randomisation phase, the number of prescription errors detected was significantly lower in the intervention group than that in the control group (129 vs. 270; p < 0.001). Similarly, prescription errors reaching the patient were significantly reduced from 40% (n = 108) in the control group to 1.6% (n = 2) in the intervention group. In the pre- and post-intervention periods, the prescription lines containing prescription errors decreased from 3.4% to 1.5% (p = 0.005).

Conclusions

This study showed that the pharmaceutical validation process decreased both the number of errors in the electronic prescribing tools and the number of prescription errors reaching the patient.

An Overview of Parenteral Nutrition from Birth to Adolescence Based on a Composite Fish Oil Containing Lipid Emulsion and a Pediatric Amino Acid Solution

Intestinal failure (IF) is characterized by a critical reduction in functional gut mass below the minimum needed for optimal growth in children. It requires parenteral nutrition (PN) and home-PN (HPN), which is challenging in terms of meeting nutritional needs according to age, growth velocity, clinical situation, and rapid changes in fluid and electrolyte requirements. Due to these complex requirements, age-adapted multi-chamber bags (MCBs) are important additions to the nutrition armamentarium. The launch of composite fish oil (FO)-containing intravenous lipid emulsions (ILEs) heralded the development of MCBs containing these ILEs in combination with a crystalline amino acid solution adapted for pediatric use. The safety and efficacy of lipid and amino acid components in this context have been widely documented in numerous published studies. This narrative manuscript includes a review of the articles published in PudMed, Embase, and Google Scholar up to June 2023 for the age groups of term infants to children and adolescents. Preterm infants with their highly specific demands are not included. It aims to offer an overview of the clinical experience regarding the use of a composite FO-based ILE and a developed specific amino acid solution.

Negative Outcomes Associated with Medication in Neonates on Parenteral Nutrition Therapy

OBJECTIVE

In Ecuador, studies on clinical daily practice problems focused on parenteral nutrition in neonates are scarce. Therefore, this research aimed to identify negative results associated with medications (NRAM) in neonates with parenteral nutrition (PN) in a third-level hospital in Ecuador.

MATERIAL AND METHODS

An observational, prospective, descriptive study was designed in the neonatology area of a tertiary-level public hospital, where, for over four months, the medical records, PN prescriptions, and pharmacy-managed databases of 78 patients were analyzed. Drug-related problems (DRPs) as possible causes of NRAM were classified through administrative, physicochemical, and clinical validation.

RESULTS

DRPs classified as follows were found: 78.81% by physicochemical, 17.62% by clinical, and 3.57% by administrative validation. The NRAM were 72% quantitatively uncertain, 16% needed, and 11% quantitatively ineffective.

CONCLUSION

The NRAM associated with DRPs were statistically related to prematurity condition, APGAR score, PN time, and the number of medications administered, which suggests the need to create a nutritional therapy committee at the health facility.

Good handling practice of parenterally administered medicines in neonatal intensive care units - position paper of an interdisciplinary working group

This position paper, developed by an interdisciplinary expert group of neonatologists, paediatric infectious disease physicians, clinical pharmacists and specialists for the prevention and control of nosocomial infections, describes the "Good handling practice of medicines parenterally administered to patients on NICUs". It takes equal account of patient safety and the specialties of neonatal intensive care regarding feasibility and proportionality. The overall concept is perceived as a "learning system", in which open communication within the health-care team relating to medication errors and critical incidents enables continuous development and improvement to ensure patient safety. In our opinion, pharmacists, who are responsible for the supply of ready-to-administer parenteral medicinal products for neonatal intensive care patients, as well as the hygiene staff responsible on site are integral parts of the interdisciplinary treatment team. Risks of the current clinical practice of parenteral treatment of NICU patients are discussed in detail and recommendations for safety-relevant procedures are given.

Patient Safety Incidents Related to the Use of Parenteral Nutrition in All Patient Groups: A Systematic Scoping Review

INTRODUCTION

There is limited comprehensive literature focussing on the range of patient safety incidents related to parenteral nutrition (PN).

OBJECTIVE

The aim of this review was to examine patient safety incidents related to the use of PN in all patient age groups.

METHODS

Literature published in the English language between January 2000 and April 2020 were searched across the MEDLINE, CINHAL and Embase databases. Articles were included if they contained PN-related patient safety incidents related to an avoidable event. No restrictions were applied to patient populations. The screening process was undertaken independently by two authors.

RESULTS

In total, 108 records were included in the review: 52 case studies, 54 observation studies (e.g. prevalence studies, surveys) and two experimental studies. All age groups were represented, with 62% of studies in paediatrics (of which two-thirds were neonates) and 23% in adults. They included all medication processes: prescribing, dispensing, compounding, administration and monitoring. Incidents were related to microbial contamination, venous access and specific components (e.g. lipid emulsion, amino acids, glucose, micronutrients and electrolytes) or the whole product. Incident outcomes ranging from near miss to death were reported. Intervention studies looked at the impact on patient safety incidents of computerised tools, healthcare processes, e.g. pharmacist screening, and standardisation. One study demonstrated more severe outcomes with paediatric than with adult PN.

CONCLUSIONS

This review demonstrates the vast range of PN-related patient safety incidents in all patient age groups and all medication process stages. The need for a national study looking at patient safety incidents related to PN in England is highlighted.

Systemic Causes of In-Hospital Intravenous Medication Errors: A Systematic Review

OBJECTIVES

Delivery of intravenous medications in hospitals is a complex process posing to systemic risks for errors. The aim of this study was to identify systemic causes of in-hospital intravenous medication errors.

METHODS

A systematic review adhering to PRISMA guidelines was conducted. We searched MEDLINE (Ovid), Scopus, CINAHL, and EMB reviews for articles published between January 2005 and June 2016. Peer-reviewed journal articles published in English were included. Two reviewers independently selected articles according to a predetermined PICO tool. The quality of studies was assessed using the GRADE system and the evidence analyzed using qualitative content analysis.

RESULTS

Eleven studies from six countries were included in the analysis. We identified systemic causes related to prescribing (n = 6 studies), preparation (n = 6), administration (n = 6), dispensing and storage (n = 5), and treatment monitoring (n = 2). Administration, prescribing, and preparation were the process phases most prone to systemic errors. Insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications were the leading causes of intravenous medication errors. The number of the included studies was limited, all of them being observational studies and graded as low quality.

CONCLUSIONS

Current intravenous medication systems remain vulnerable, which can result in patient harm. Our findings suggest further focus on medication safety activities related to administration, prescribing, and preparation of intravenous medications. This study provides healthcare organizations with preliminary knowledge about systemic causes of intravenous medication errors, but more rigorous evidence is needed.

Parenteral Nutrition Process Management for Newborn and Preterm Infants - A Preliminary Risk Analysis

BACKGROUND

There are variable practices in the management of the parenteral nutrition (PN) process in hospitals having a neonatal intensive care unit (NICU). In our hospital, PN is prepared partially on the neonatal ward by nurses but also at the central pharmacy by trained pharmacy technicians. A previous study showed a concentration non-conformity of 34% of on-ward PN preparations potentially resulting in under- or overfeeding of the patients.

OBJECTIVE

The objectives were to perform preliminary risk analyses (PRA) in preparation for our hospital's transition to universal central pharmacy PN compounding.

METHODS

A working group including pharmacists, neonatologists, nurses, and pharmacy technicians performed two PRA. The risks of 9 management steps of the PN process were identified, evaluated, and quoted. A comparison of the number of risks and their criticality index (CI) was conducted.

RESULTS

A total of 36 and 39 risks were identified for PN preparation in the NICU and the pharmacy, respectively. For the NICU, ten risks (28%) had an "acceptable" CI, 15 risks (42%) were "under control" and eleven (31%) were defined as "non-acceptable". For the pharmacy, 14 risks (36%) had an "acceptable" CI, 19 risks (49%) were "under control" and six (15%) were defined as "non-acceptable". Risks directly related to the preparation process, including the steps preparation hood, PN preparation and analytical quality control, represented a cumulated CI of 145 for eleven NICU-risks vs 108 for twelve pharmacy risks (-26%). The implementation of immediate improvement measures, eg, an electronic prescription form, reduces the total CI by 5.7% and 2.2% for the NICU and the pharmacy, respectively.

CONCLUSION

This PRA highlighted the safety differences between PN preparation in the NICU vs the pharmacy at our institution, and facilitated our moving forward with a process change that should improve the care of our neonatal patients. Nevertheless, long-term improvement measures have to be implemented to further reduce risks related to the PN management process.

A Pre-Post Intervention-Based Study Investigating the Impact of Standardized Parenteral Nutrition at Tertiary Neonatal Intensive Care Unit in Karachi, Pakistan

Introduction

Conventionally, various parenteral nutrition (PN) components are individually administered considering an individual neonate's requirements. More recently, standardized PN (SPN) formulations have been initiated for preterm neonates, which may benefit from the enhanced nutrient supply, less administration and prescription errors, reduced risk of infectious disease, and cost-effectiveness.

Methodology

A multicentered, pre-post intervention-based study was conducted at tertiary neonatal intensive care units (NICUs) in Karachi, Pakistan. Post-graduate residents of neonatology and pediatrics working in NICUs were included in the study, and their perspective was attained regarding PN formulation and a prescription for time consumption, ease, calculation errors, and general feedback. Independent T-test was applied to assess the statistical difference between the pre-and post-implementation of PN formulation for total time required for PN calculation, whereas for the rest of the quantitative variables Mann-Whitney U test was computed.

Results

The total time required to do the entire writing process, calculating and ordering PN, was 17.1±6.9 whereas significantly (p-value of <0.0001) reduced to 10.5±5.7 after implementing SPN prescriptions. Calculation errors were reduced from 32% to 12%, and writing errors were also decreased from 35% to 8% when the standardized parenteral nutritional formulation was applied.

Conclusion

Our findings show that implementing standardized prescriptions in the NICU has improved medication safety, with the most consistent benefit by reducing medication errors and time management. The SPN prescriptions save time for post-graduate residents, physicians, and pharmacists by eliminating previously required repetitive activities and calculations.

Parenteral Nutrition Prescribing and Order Review Safety Study: The Need for Pharmacist Intervention

INTRODUCTION

Errors have been reported in the literature to occur at each step of the parenteral nutrition (PN) use process, necessitating standardized processes, clinician competence, and open communication for those involved. This study was performed at Central Admixture Pharmacy Services (CAPS®) in collaboration with the American Society for Parenteral and Enteral Nutrition (ASPEN) with the purpose to study the need for and success of PN pharmacist interventions.

METHODS

A survey was developed and sent to all CAPS customers for study enrollment and to identify their demographic and practice characteristics. For those enrolled, CAPS pharmacists reviewed every PN order in a 1-month period using an error/intervention tool to capture data on prescription elements requiring intervention, along with acceptance of that intervention.

RESULTS

Two hundred thirty-two unique CAPS customers (23% response rate) participated in the study, representing 37,634 unique PN prescriptions. Two hundred forty-eight PN prescriptions (0.66%) from 59 customers required ≥1 intervention. The top 3 intervention types were electrolyte dose clarification, calcium/phosphorus incompatibility, and amino acid dose clarification. A greater number and percentage of interventions were required for neonatal prescriptions, as compared with adult and pediatric prescriptions. No significant difference was found in many of the other customer characteristics.

CONCLUSION

This study supports the need for institutions to develop systems to comply with published PN safety recommendations, including knowledgeable and skilled pharmacists to complete the order review and verification steps for this high-alert medication.

Current State of Nutrition Education in Pediatric Critical Care Medicine Fellowship Programs in the United States and Canada

OBJECTIVES

To assess the current state of nutrition education provided during pediatric critical care medicine fellowship.

DESIGN

Cross-sectional survey.

SETTING

Program directors and fellows from pediatric critical care medicine fellowship programs in America and Canada.

SUBJECTS

Seventy current pediatric critical care medicine fellows and twenty-five pediatric critical care medicine fellowship program directors were invited to participate.

INTERVENTIONS

Participants were asked demographic questions related to their fellowship programs, currently utilized teaching methods, perceptions regarding adequacy and effectiveness of current nutrition education, and levels of fellow independence, comfort, confidence, and expectations in caring for the nutritional needs of patients.

MEASUREMENTS AND MAIN RESULTS

Surveys were sent to randomly selected program directors and fellows enrolled in pediatric critical care medicine fellowship programs in America and Canada. Twenty program directors (80%) and 60 fellows (86%) responded. Ninety-five percent of programs (19/20) delivered a formal nutrition curriculum; no curriculum was longer than 5 hours per academic year. Self-reported fellow comfort with nutrition topics did not improve over the course of fellowship (p = 0.03), with the exception of nutritional aspects of special diets. Sixty-five percent of programs did not hold fellows responsible for writing daily parenteral nutrition prescriptions. There was an inverse relationship between total number of fellows in a pediatric critical care medicine program and levels of comfort in ability to provide parenteral nutrition support (p = 0.01). Program directors perceived their nutritional curriculum to be more effective than did their fellows (p ≤ 0.001).

CONCLUSIONS

Nutrition education was reported as highly underrepresented in pediatric critical care medicine fellowship curricula. The majority of programs rely on allied health care professionals to prescribe parenteral nutrition, which may influence trainee independence in the provision of nutritional therapies. Improving the format of current nutrition curriculums, by relying on more active teaching methods, may improve the delivery and efficacy of nutrition education. The impact of novel training interventions on improving the competency and safety of enteral and parenteral nutrition delivery in the PICU must be further examined.

Assessment and Optimization of the Pediatric Parenteral Nutrition Preparation Process in a Hospital Pharmacy

BACKGROUND

Parenteral nutrition (PN) is associated with risks that could threaten the clinical condition of premature neonates hospitalized in the neonatal intensive care unit. In this work, risk-analysis methodology was implemented to contain the risks associated with the PN production process and improve PN safety.

METHODS

The Failure Modes, Effects, and Criticality Analysis was performed by a multidisciplinary team. All potential failure modes of the PN preparation process were recorded, and associated risks were scored based on their severity, occurrence, and detectability, with a risk priority number (RPN). All identified failure scenarios and the respective work stages were ranked in descending order of criticality. Corrective actions were proposed to address critical points, and the safety of the process was reassessed by the same method in a prospective manner.

RESULTS

The highest RPN scores were obtained with the PN composition calculation performed manually (RPN: 530) or electronically (RPN: 478), completion of the PN medical order form (RPN: 354), manual compounding of PN admixtures (RPN: 258), and the structure/organization/maintenance of the PN preparation unit (RPN: 133). The quality and safety of PN admixtures could be compromised by many critical factors, such as the increased particle-microbial load in the unit and the inadequate training/experience of the involved health professionals and their incompliance with the given instructions. The implementation of the proposed corrective measures is expected to reduce the risks of the overall PN production process by 67.5%.

CONCLUSIONS

Improvement of the PN production process through risk-analysis methodologies enhances safety for premature neonates.

Parenteral nutrition: a call to action for harmonization of policies to increase patient safety

Unsafe medication practices and medication errors are leading causes of injury and avoidable harm worldwide and are highest in vulnerable groups. In 2017, the World Health Organization launched the third Medication Without Harm Global Patient Safety Challenge to try to reduce risks related to medical treatment. Parenteral nutrition (PN) is in the unique position that, although licensed products are available from manufacturers, formulas may be prepared ad hoc for first-line use that might not be subject to the same regulatory oversight. Safety issues around PN can arise through lack of harmonization in practices, misinterpretation and product unfamiliarity and can occur at any stage from prescription to preparation to administration. Government legislation and regulation vary considerably, with PN not explicitly handled in many countries. We therefore call on policy leaders in all countries to establish policies that ensure patient safety, and that these include PN along with medicines. The available evidence supports obtaining industry prepared PN as first-line therapy for reasons of safety, primarily, and of cost. If a suitable industry prepared ready-to-use PN is not available, standardized all-in-one PN admixtures should be the next line of care, with individualized PN being reserved for patients whose complex nutritional needs cannot be met using standardized admixtures.

Value of pharmacy services in an outpatient, preoperative, anesthesia clinic

OBJECTIVE

This pilot study assessed the expansion of pharmacy services to a preoperative, anesthesia clinic.

SETTING

Tertiary care academic medical center.

PRACTICE DESCRIPTION

Medication histories were routinely obtained by clinic nurses, and pharmacy services were not available.

PRACTICE INNOVATION

A prospective, single-center, pilot study enrolled English-speaking patients aged 65 years or older in a preoperative clinic before a scheduled surgery. Patient attributes including health literacy and preparatory activities were measured using verbal and written questionnaires. Home medication lists were obtained by both clinic nurses (routine care) and a pharmacist (research), and the 2 lists were compared to identify medication discrepancies for each patient. Discrepancies were categorized by type and severity.

EVALUATION

This study evaluated the potential impact of medication histories obtained by pharmacists compared with those obtained by clinic nurses during geriatric preoperative clinic visits.

RESULTS

Of the 44 patients who gave their consent and were included in this pilot study, 25% (n = 11) had limited/marginal written and verbal health literacy, and 20% (n = 9) had limited/marginal numerical health literacy. Of the 38 patients who completed the pharmacist medication history interview, only 21% (n = 8) brought a complete list of their current medications to the preoperative clinic, 95% (n = 36) had at least 1 medication discrepancy, and 61% (n = 23) had at least 1 clinically meaningful discrepancy. Clinically meaningful discrepancies were identified for 8% (35 of 459) of medications and occurred most commonly for blood pressure medications, nonsteroidal anti-inflammatory drugs, and beta blockers.

CONCLUSION

In this study, medication history discrepancies identified by pharmacists suggest that the expansion of pharmacy services into the preoperative clinic is feasible and could potentially prevent meaningful medication errors among geriatric patients being admitted for a scheduled surgery.

Quality and safety of parenteral nutrition for newborn and preterm infants as an on-ward preparation

BACKGROUND

For newborn and preterm infants, standardised and individual parenteral nutrition (PN) is used. PN preparation is at risk for contamination and dosing errors. The quality of PN is crucial for infants and has a direct impact on their health status and safety.

PURPOSE

The aim of this study is to evaluate the physicochemical and microbial quality of PN for newborn and preterm infants prepared on a neonatal ward.

METHODS

Sampling of various individual PN prepared by nurses on a neonatal ward was performed. Formulations included maximal four electrolytes, variable dextrose and amino acid concentrations. Depending on the sample volume, up to three quality analyses were performed: (1) test for bacterial endotoxins by kinetic-chromogenic method, (2) sterility according to the European and US Pharmacopoeia, and (3) quantification of electrolytes by capillary electrophoresis and of dextrose by ultraviolet detection after enzymatic reaction of hexokinase. The concentrations obtained were evaluated based on the US and Swiss Pharmacopoeia specifications for compounded preparations and compared to the widened pharmacy specifications.

RESULTS

The composition of 86% of the 110 analysed PN prepared by nurses on the neonatal ward corresponded to their medical prescription. 14% were out of the acceptable widened pharmacy ranges. We found no microbial contamination in the samples. All PN were free from endotoxins.

CONCLUSION

Component concentrations of PN prepared on wards by nurses differed frequently and significantly from their medical prescription, and the deviation can be critical depending on the component and its mode of action. The sample size is too small to evaluate the microbial contamination.

The Responsibility of Clinical Pharmacists for the Safety of Medication Use in Hospitalized Children: A Middle Eastern Experience

Objective:

We aimed to detect and report the frequency of occurrence of drug-related problems (DRPs) in a Middle Eastern University Children's Hospital (Isfahan, Iran) and classify them in terms of their nature and cause to clarify the responsibility of clinical pharmacists for the safe utilization of medications in hospitalized children.

Methods:

In this cross-sectional study which was carried out in Imam Hossein Children's University Hospital affiliated with Isfahan University of Medical Sciences (Isfahan, Iran) from September 2017 to May 2018, DRPs during the hospitalization of pediatric patients in three medical wards, the pediatric intensive care unit, and two neonatal intensive care units were detected and identified concurrently with the treatment process using Pharmaceutical Care Network of Europe data gathering form for DRPs v. 8.01. All cases were verified and validated in a professional focus group before documentation.

Findings:

We detected 427 DRPs in 201 out of 250 randomly included hospitalized children in which 86% of them were directly reported by the hospital's clinical pharmacist. The highest frequency of DRPs (47.3%) was observed in the age range of 1 month–2 years. Safety of treatment was the most frequently reported as the nature of the problem (43.5%), followed by effectiveness issues (36.8%). The most frequent cause of DRPs was dose selection issues (34.2%), followed by drug-type selection (25.5%), and unavailability of appropriate dosage forms (13.6%). Ninety-eight interventions were proposed by the clinical pharmacist, in which 59.2% of them were accepted.

Conclusion:

This study confirms the necessity for the active role of clinical pharmacists before, during, and after drug therapy in hospitalized pediatric patients for the safety and proper utilization of drugs in this vulnerable population.

Failure Mode, Effect, and Criticality Analysis of the Parenteral Nutrition Process in a Mother-Child Hospital: The AMELIORE Study

BACKGROUND

The parenteral nutrition (PN) process is complex and involves multiple steps and substeps, especially in pediatrics and neonatology, given the particular needs of these patients. The objective of this study was to perform a critical analysis of the PN process at the Centre Hospitalier Universitaire Sainte-Justine to determine which potential pitfalls are related to this process and which should be prioritized when implementing corrective measures.

METHODS

This is a Failure Mode, Effect, and Criticality Analysis (FMECA) study. A multidisciplinary team assessed each step of the PN process and identified associated failure modes. Adapted rating scales were used to determine severity, frequency, and detectability of the failure modes. Ratings were established through multidisplinary consensus, and a criticality index (CI) was calculated for each failure mode.

RESULTS

A total of 265 failure modes were identified in the 5 major steps of the PN process. The failure mode with the highest CI was the inscription of an inaccurate weight at prescription, with a CI of 800. The step with the highest cumulative CIs was administration to patients, with a CI sum of 7691. Various recommendations aimed at minimizing the risks associated with the PN process were made following this FMECA. Additional interventions are expected to emanate from this project because data will be presented throughout the departments involved.

CONCLUSION

This study is a successful example for other hospitals interested in carrying out the same kind of healthcare improvement initiative.