Parenteral nutrition (PN), a critical component of nutrition care, is a high-alert medication that provides life-saving medical care to patients who cannot maintain adequate enteral caloric intake. PN is also among the most complicated medications that pharmacy prepares; preparations can contain up to 40 nutrient components, including amino acids, dextrose, IV fat emulsion, electrolytes, vitamins, and minerals. With significant room for error, instituting a safety-focused PN process is critical to ensuring the health of patients receiving PN (see the SIDEBAR1-4 for potential errors in the PN process).
Steps in the Process
A multitude of steps are required to ensure the PN process is safe and accurate5:
Policies and procedures (P&Ps) for each of these steps must be developed to ensure safe PN delivery. In addition, due to the complex nature of the PN process, PN management should involve an interdisciplinary team. In recent years, PN prescribing has evolved to include not only physicians but also pharmacists, nurse practitioners, physician assistants, and dieticians. Careful consideration throughout all stages of the medication-use process is essential to ensuring safe PN ordering, order review, compounding, and administration.
Proper PN prescribing is essential for safe delivery of the therapy. Those prescribing PN should have in-depth knowledge of energy requirements, fluids, electrolytes, and acid-base disorders. Prescribers must also understand the appropriate indications for PN and the required vascular access needed for administration.
Instituting a standardized PN ordering process can reduce errors, improve efficiency, and minimize waste. Utilizing computerized prescriber order entry (CPOE) systems eliminates the possibility of transcription errors and further increases patient safety.6 In fact, one study reports that the utilization of computerized orders leads to a 43% reduction in dosing errors and a 66% reduction in total prescribing errors in adult patients.7
Due to reports of multiple errors related to PN prescribing, the Institute for Safe Medication Practices (ISMP) released PN safe practice recommendations, listed in TABLE 3.8 While the initial prescription of PN must be accurate, it is important to also note that patients often require a prolonged duration of PN therapy. Therefore, the reordering process should occur in its entirety, using full generic names and doses. This reordering process should also require built-in accountability for those reviewing the order, including evaluation of laboratory results and patient condition.
The pharmacist’s review of the order is an essential step in the PN process. Develop and maintain a seamless verification process to avoid error and patient harm. When reviewing the PN order, consider the following:
Compounding the PN Order
Training and Competency
It is not uncommon for PN compounding errors to result due to a knowledge deficit and/or a lack of training. Health care organizations should require annual competency evaluations of pharmacists and pharmacy technicians who prepare PN orders.6
Consider in-house compounding for PN orders provided the institution has the appropriate resources and staffing to prepare PN orders.6
Preparation of the PN order should be driven by well-defined P&Ps. Moreover, standard workflow processes should direct the entire compounding process from assessment through documentation.
If an automated compounding device (ACD) is used, P&Ps must be implemented and followed to ensure safe, effective preparation of PN admixtures. In addition11, 12:
Manual compounding should be avoided whenever possible, although it may be required in certain circumstances such as when there is an interaction between a PN component and a part of the ACD, if there is a shortage of a specific PN component, or if the volume of a component is less than what the ACD can deliver.
At least three verifications of the PN order should occur in the pharmacy: first, upon initial order entry, then before compounding, and third, after the PN has been compounded.13
PN compounding should be conducted in a physical environment that promotes safety throughout the entire process.
Review the Process Frequently
Review the compounding process frequently for any compliance issues and ensure that any necessary corrective actions occur.
Proper administration is essential to a safe PN process. Because this is a high-alert medication, P&Ps detailing the administration steps should be developed and integrated into practice to promote patient safety and reduce the risk of errors.14 Consider the following issues when developing P&Ps:
Depending on the type of PN formulation, an appropriate filter should be utilized during infusion,14 as the use of filters reduces the potential for patient harm due to particulates, microorganisms, and air emboli.6 The ASPEN Parenteral Nutrition Safety Consensus Recommendations suggest a 0.22 micron filter for dextrose/amino acid PN admixtures and a 1.2 micron filter for total nutrient admixtures.6 For peripheral administration, recommendations indicate that PN with an osmolarity up to 900 mOsm/L is well tolerated and is safe to infuse in a peripheral vein.15
Due to the complex composition of PN, it is difficult to determine its compatibility with other drugs. A pharmacist should always review the compatibility and stability data prior to any co-infusion of medication through PN lines.14
PN is a life-sustaining therapy for patients of all age groups with a variety of indications. When delivered with a patient safety mindset, PN proves to be a complex but safe therapy. Complications and adverse events associated with PN are often a result of breakdowns in the PN process; therefore, those responsible for PN management should be well versed in all steps of its use.
Phil Ayers, PharmD, BCNSP, FMSHP, FASHP, is chief of clinical pharmacy services at Mississippi Baptist Medical Center. He received his BS in pharmacy and his PharmD from the University of Mississippi, where he is a clinical associate professor.
Andrew Mays, PharmD, CNSC, is a clinical pharmacy specialist in nutrition support at the University of Mississippi Medical Center in Jackson. He is a clinical assistant professor at the University of Mississippi School of Pharmacy.
Allison Cochran, DNP, is a registered nurse in the emergency department at University of Mississippi Medical Center in Jackson. She is a recent graduate of Loyola University New Orleans Doctor of Nursing Practice program and received her BSN from Louisiana State University Health Sciences Center.
Caroline Bobinger, PharmD, is a clinical pharmacy specialist at Baptist Medical Center in Jackson, Mississippi. She received her BS in pharmacy and her PharmD from the University of Mississippi.
Jenny Anderson, MS, RD, LD, CNSC, is a registered dietitian at Baptist Health Systems in Jackson. She completed her undergraduate degree in nutrition and dietetics at the University of Southern Mississippi and her Master’s Degree from the University of Alabama.
ISMP’s Safe Practice Recommendations for Parenteral Nutrition8
ISMP=Institute for Safe Medication Practices
Errors in the PN Process
The Institute for Safe Medication Practices (ISMP) deems PN a high-alert medication, a designation that indicates it may cause significant patient harm if used in error.1 For example:
In 2012, Storey et al evaluated PN errors reported to MEDMARX and characterized them by node.4 The MEDMARX Database Severity Scale is described in TABLE 1. See TABLE 2 for PN-specific errors reported to MEDMARX.
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