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

Mistry, Priya; Smith, Rebecca; Fox, Andy

doi:10.1007/s40264-021-01134-3

Cited by 7 publications

(2 citation statements)

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“…These drugs have also been observed to cause severe paediatric MEs in other studies [ 7 , 12 , 14 , 31 , 37 ]. Although we found common MEs related to parenteral nutrition and concentrated electrolytes, supporting the previous evidence [ 12 , 30 , 31 , 38 ], the number of serious MEs remained low. However, several paediatric studies have identified these drugs as high-alert medications [ 17 – 21 ].…”

Section: Discussionsupporting

confidence: 89%

Medication errors related to high-alert medications in a paediatric university hospital – a cross-sectional study analysing error reporting system data

Kuitunen,

Saksa,

Tuomisto

et al. 2023

BMC Pediatr

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Background Paediatric patients are prone to medication errors, and only a few studies have explored errors in high-alert medications in children. The present study aimed to investigate the prevalence and nature of medication errors involving high-alert medications and whether high-alert medications are more likely associated with severe patient harm and higher error risk classification compared to other drugs. Methods This study was a cross-sectional report of self-reported medication errors in a paediatric university hospital in 2018–2020. Medication error reports involving high-alert medications were investigated by descriptive quantitative analysis to identify the prevalence of different drugs, Anatomical Therapeutic Chemical groups, administration routes, and the most severe medication errors. Crosstabulation and Pearson Chi-Square (χ2) tests were used to compare the likelihood of more severe consequences to the patient and higher error risk classification between medication errors involving high-alert medications and other drugs. Results Among the reported errors (n = 2,132), approximately one-third (34.8%, n = 743) involved high-alert medications (n = 872). The most common Anatomical Therapeutic Chemical subgroups were blood substitutes and perfusion solutions (B05; n = 345/872, 40%), antineoplastic agents (L01; n = 139/872, 16%), and analgesics (N02; n = 98/872, 11%). The majority of high-alert medications were administered intravenously (n = 636/872, 73%). Moreover, IV preparations were administered via off-label routes (n = 52/872, 6%), such as oral, inhalation and intranasal routes. Any degree of harm (minor, moderate or severe) to the patient and the highest risk classifications (IV-V) were more likely to be associated with medication errors involving high-alert medications (n = 743) when compared to reports involving other drugs (n = 1,389). Conclusions Preventive risk management should be targeted on high-alert medications in paediatric hospital settings. In these actions, the use of intravenous drugs, such as parenteral nutrition, concentrated electrolytes, analgesics and antineoplastic agents, and off-label use of medications should be prioritised. Further research on the root causes of medication errors involving high-alert medications and the effectiveness of safeguards is warranted.

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Section: Discussionsupporting

confidence: 89%

Medication errors related to high-alert medications in a paediatric university hospital – a cross-sectional study analysing error reporting system data

Kuitunen,

Saksa,

Tuomisto

et al. 2023

BMC Pediatr

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“…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.…”

Section: Introductionmentioning

confidence: 99%

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

2023

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BackgroundParenteral nutrition (PN)–related patient safety incidents have been associated with harm. Large‐scale studies are scarce, and little is known about contributory factors. This study evaluated PN‐related incident reports that described harm using a national database.Materials and MethodsA retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death.Results12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors.ConclusionsThis is the first evaluation of PN‐related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high‐risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.

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Patient safety incidents related to parenteral nutrition

2022

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

Cited by 7 publications

References 115 publications

Medication errors related to high-alert medications in a paediatric university hospital – a cross-sectional study analysing error reporting system data

Medication errors related to high-alert medications in a paediatric university hospital – a cross-sectional study analysing error reporting system data

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

Patient safety incidents related to parenteral nutrition

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