An unusual case of refractory hypoglycaemia in a neonate receiving total parenteral nutrition

National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system

“…Content analysis of the free‐text fields provided a more granular insight and revealed that specific ingredients such as intravenous ILEs, amino acids, electrolytes, dextrose, and micronutrients were involved in PN‐related incident reports. This resembles the findings from previously discussed case reports and prevalence studies 17,23,27,29,31,32,46–48 . Inadvertently administrating ILE at the rate of the nonlipid PN, and vice versa, in neonates and infants was a common incident type seen in our study and literature 27,31,46,48 .…”

“…The single most common medication process reported for both adults and children, and for all reported degrees of harm, was administration. This was in agreement with the study by Storey et al 29 and several published case studies 16–18,24,27,28 . In the UK, it is recommended that additions to PN bags, including multichamber bags, only occur in the pharmacy aseptic unit 40 .…”

“…These incident reports were found to be the result of insufficient monitoring or inappropriate venous access devices—for example, peripheral intravenous route used for high‐osmolarity PN that should only be infused centrally. Extravasation injuries in infants due to PN have been recognized in several case reports and have also been highlighted by this study 15–18 . Incident reports related to the wrong dose being administered were frequently related to an error being made by healthcare staff, although they were difficult to categorize further because of insufficient information.…”

“…This was in agreement with the study by Storey et al 29 and several published case studies. [16][17][18]24,27,28 In the UK, it is recommended that additions to PN bags, including multichamber bags, only occur in the pharmacy aseptic unit. 40 This may vary in other parts of the world, and studies have described the supplementation of micronutrients and/or electrolytes to multichamber bags in a clinical setting.…”

“…A recent review of the literature suggests PN-related incidents occur during any part of the medication process and in all patient age groups, although children may be more susceptible to harmful outcomes. 10 Incident types were divided into the following categories: microbial contamination, [11][12][13][14] venous access incidents involving extravasation, [15][16][17][18][19] and incidents related to specific PN components or the compounded bag. [20][21][22] Lipid injectable emulsion (ILE), dextrose, electrolyte, and micronutrient components of PN have been involved in case reports.…”