Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding

Mackay, M. F.; Anderson, Collin; Boehme, Sabrina; Cash, Jared; Zobell, Jeffery T.

doi:10.1177/0884533615591606

Cited by 50 publications

(50 citation statements)

References 20 publications

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“…Brown et al only defined three prescribing error types (volume error, calcium/phosphate solubility error, osmolarity error) (16). In contrast to our study, MacKay et al assigned compatibility errors to the administration process, not to prescribing (29). …”

Section: Discussioncontrasting

confidence: 99%

“…MacKay et al conducted a similar study in a children’s hospital. Most errors arose during administration (29). Both studies reported a rate of MEs related to the prescription, transcription, preparation and administration of PN of only 6% (28) and 0.27% (29).…”

Section: Discussionmentioning

confidence: 99%

“…Most errors arose during administration (29). Both studies reported a rate of MEs related to the prescription, transcription, preparation and administration of PN of only 6% (28) and 0.27% (29). In contrast to our study, the errors observed in the study of Sacks et al, excluding the prescribing errors, were not detected before preparation.…”

Section: Discussionmentioning

confidence: 99%

“…In the study of Sacks et al, six (8%) of the 74 errors contributed to or resulted in temporary harm to the patient (28). In the study of MacKay et al, 21 (9.1%) of 230 errors were classified as to have potentially contributed to temporary harm (category E, F) (29). …”

Section: Discussionmentioning

confidence: 99%

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

et al. 2017

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ObjectivesPediatric inpatients are particularly vulnerable to medication errors (MEs), especially in highly individualized preparations like parenteral nutrition (PN). Aside from prescribing via a computerized physician order entry system (CPOE), we evaluated the effect of cross-checking by a clinical pharmacist to prevent harm from PN order errors in a neonatal and pediatric intensive care unit (NICU/PICU).MethodsThe incidence of prescribing errors in PN in a tertiary level NICU/PICU was surveyed prospectively between March 2012 and July 2013 (n = 3,012 orders). A pharmacist cross-checked all PN orders prior to preparation. Errors were assigned to seven different error-type categories. Three independent experts from different academic tertiary level NICUs judged the severity of each error according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index (categories A–I).ResultsThe error rate was 3.9% for all 3,012 orders (118 prescribing errors in 111 orders). 77 (6.0%, 1,277 orders) errors occurred in the category concentration range, all concerning a relative overdose of calcium gluconate for peripheral infusion. The majority of all events (60%) were assigned to categories C and D (without major harmful consequences) while 28% could not be assigned due to missing majority decision. Potential harmful consequences requiring interventions (category E) could have occurred in 12% of assessments.ConclusionNext to systematic application of clinical guidelines and prescribing via CPOE, order review by a clinical pharmacist is still required to effectively reduce MEs and thus to prevent minor and major adverse drug events with the aim to enhance medication safety.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

et al. 2017

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“…Electronic medication prescribing and atuomated dose checking [36][37][38][39][40][41][42][43][44][45][46][47][48][49][50] Computerized physician order entry (n = 5)…”

Section: Intervention Type Example Of Intervention Referencesmentioning

confidence: 99%

Interventions to reduce medication errors in neonatal care: a systematic review

Nguyen

Mosel

Grzeskowiak

2017

Therapeutic Advances in Drug Safety

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Background: Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. Methods: A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and referencelist checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. Results: A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50-70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. Conclusion: While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice.

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Use of Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects

Boullata

Berlana

Piętka³

et al. 2020

J Parenter Enteral Nutr

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A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi‐chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration.

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Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding

Cited by 50 publications

References 20 publications

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

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

Interventions to reduce medication errors in neonatal care: a systematic review

Use of Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects

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