Parenteral Nutrition Prescribing Processes Using Computerized Prescriber Order Entry

Abstract

The prescribing and processing of parenteral nutrition (PN) orders for pediatric patients may involve multiple steps, be time-consuming, and have opportunity for error if safety measures are not in place. The process can vary from institution to institution. The authors conducted a comparison of their system for the prescribing and processing of PN orders with the American Society for Parenteral and Enteral Nutrition's (A.S.P.E.N.'s) Safe Practices for Parenteral Nutrition guidelines. Using a computerized prescriber order entry (CPOE) system allowed for compliance with most of the elements. The safety data demonstrated an overall low rate of transcription errors, an inherent risk when the CPOE system does not communicate directly with the automated compounding device (ACD). There was a 5% overall pharmacist intervention rate on PNs, similar to the 6%-8% rate seen with other medications. Approximately 6% of these PN interventions had an outcome associated with preventing an adverse drug reaction, toxicity, or medication error. Implementation of additional safety measures and standardization may have a positive impact on the complicated process of prescribing and processing PN orders at the authors' institution.

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

“…Further studies are needed to determine the upper concentration range of calcium in PN with an acceptable risk of thrombophlebitis and necrosis, still ensuring a sufficient supply for newborns with calcium. While the second major error category “dosage” was responsible for 11.9% of errors in our study, 39% ( n  = 139) of the interventions by the clinical pharmacist in the study of Hilmas and Peoples were related to errors of dosage and composition (31). Of all events, 6% were errors that could have resulted in an adverse drug reaction, medication error, or toxicity.…”

“…Brown et al reduced the neonatal PN prescribing error rate by introducing a computerized PN worksheet from 14.5 to 6.8% (16); Lehmann et al reduced the error rate from 10.8 to 4.2% and 1.2% in a NICU in two intervention periods by introducing an online total PN order entry system (30). In the study of Hilmas and Peoples, a clinical pharmacist in a pediatric hospital had to intervene in 5% of PN orders (31). As in our study a clinical pharmacist prevented adverse drug events.…”

A Parenteral Nutrition Use Survey With Gap Analysis

“…Introduction of CPOE systems with decision support tools is expected to reduce errors and improve patient care when approached systematically and comprehensively by an organization 23 . A CPOE system can improve the safety in the PN use process 24 . Not only does CPOE reduce the rate of medication errors, but it may also result in a favorable return on investment 25 – 27 .…”

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

“…The six intervention types included: technology (n = 38), organizational (n = 16), [56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71] personnel (n = 13), [72][73][74][75][76][77][78][79][80][81][82][83][84] pharmacy (n = 9), [85][86][87][88][89][90][91][92][93] hazard and risk analysis (n = 8), 10,[93][94][95][96][97][98][99] and multifactorial (i.e. a combination of any of the previous themes; n = 18).…”

“…Development of preformatted medication order sheets [56][57][58][59][60][61][62][63][64] Medication distribution and supply (n = 6) Preparation of prediluted medications for administration [65][66][67][68][69][70] Nurse prescribing (n = 1) Transcription of paper-based orders to electronic orders by nursing staff 71 Personnel (n = 13) Staff education (n = 13) Personalized feedback of medication prescribing errors [72][73][74][75][76][77][78][79][80][81][82][83][84] Pharmacy (n = 9) Ward based (n = 6) Interventions identified through introduction of ward-based paediatric/neonatal clinical pharmacy service [85][86][87][88][89][90] Dispensary based (n = 3) Interventions identified through dispensary-based pharmacy service [91][92][93] Hazard and risk analysis (n = 8) Quality improvement tools (n = 4) Use of failure modes, effects, and criticality analyses to redesign care processes 10,[95][96][97] Error detection tools (n = 3) Automated detection of medication errors 93,…”