A neonatal intensive care unit audit of 204 parenteral nutrition (PN) orders revealed a 27.9% PN prescribing error rate, with errors by pediatric residents exceeding those by neonatal nurse practitioners (NNPs) (39% versus 16%; P < 0.001). Our objective was to reduce the PN prescribing error rate by implementing an ordering improvement process. An interactive computerized PN worksheet, used voluntarily, was introduced and its impact analyzed in a retrospective cross-sectional study. A time management study was performed. Analysis of 480 PN orders revealed that the PN prescribing error rate was 11.7%, with no difference in error rates between pediatric residents and NNPs (12.3% versus 10.5%). Use of the interactive computerized PN worksheet was associated with a reduction in the prescribing error rate from 14.5 to 6.8% for all PN orders ( P = 0.016) and from 29.3 to 9.6% for peripheral PN orders ( P = 0.002). All 12 errors that occurred in the 177 PN prescriptions completed using the computerized PN worksheet were due to avoidable data entry or transcription mistakes. The time management study led to system improvements in PN ordering. We recommend that an interactive computerized PN worksheet be used to prescribe peripheral PN and thus reduce errors.

Background: Osteopenia of prematurity is common among extremely low birth weight infants (ELBW). There are currently no standard practices regarding screening, prevention or treatment of this condition.Objective: To determine if introduction of a nutritional monitoring and interventional protocol would decrease the incidence and severity of osteopenia of prematurity.Methods: A nutritional protocol to monitor the needs and provide supplementation of calcium and phosphorus has been instituted in our unit. We compared ELBW infants born in the year before (Group 1) vs. after (Group 2) for lowest serum phosphorus, peak alkaline phosphatase and bone fractures. Logistic regression analysis was used to determine the independent effect of gestational age, birth weight, diuretics, postnatal steroids, and the nutritional protocol.Results: Osteopenia-related outcomes improved, including: phosphorus level <3 mg/dL (34% vs. 14%, (P = 0.003)), peak alkaline phosphatase >750 IU/L (18% vs. 7%, (P = 0.018)), and bone fractures (16.4% vs. 5.4%, (P = 0.026)). The use of diuretics increased significantly, while the use of postnatal steroids decreased significantly. Logistic regression analysis confirmed the independent contribution of our nutritional protocol as well as birth weight to osteopenia of prematurity outcomes.Conclusions: This is the first study to report that initiation of a protocol for monitoring and optimizing bone mineralization can decrease the incidence of severe osteopenia of prematurity as manifested by hypophosphatemia, elevated ALP and bone fractures. Implementation of a neonatal intensive care clinical practice guideline will improve this largely preventable medical complication.