Ensure Parenteral Nutrition Safety

March 2020 - Vol. 17 No. 3 - Page #26

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:

  • Assessment
  • Ordering
  • Review/verification of order 
  • Compounding/preparation
  • Dispensing
  • Administration
  • Monitoring
  • Documentation of each step

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.

Accurate Ordering

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.

Order Review

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:

  • Use a CPOE System. PN should be ordered through a CPOE system, which eliminates transcription errors. If a CPOE system is not available, PN should be prescribed using a standardized order template as an editable electronic document in order to avoid handwritten orders.6
  • Prevent Distractions. The pharmacist should work without any distractions during PN order verification.
  • Ensure Appropriate Ordering. PN ingredients should be ordered as amounts per day rather than in amounts per liter; amounts per day should be measured in macronutrients or micronutrients per day. Ordering in amounts per day reduces the potential for error that may occur when the PN order is transferred to another facility. A dose should be listed in the order for every macronutrient, electrolyte, vitamin, and trace element.6
  • Check the Indication and Route of Administration. The pharmacist should verify that the indication for PN is appropriate and that the calculated osmolarity is correct for the indicated route of administration.
  • Evaluate Every Order. Each order should be evaluated to make sure it is clinically appropriate for the patient’s needs and that all the ingredients are compatible.
  • Review the Most Recent PN Order. The order should always be compared to the previous day’s PN order to ensure there are not any substantial differences.
  • Relay Modifications. Convey any modifications of the PN order to the ordering prescriber.6
  • Institute an Independent Double-Check. An independent double-check process should be in place for all PN orders that require calculations or conversion of units of measure.9
  • Ensure Competency. Pharmacists who review PN orders should demonstrate competency at least annually.10

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

In-House Compounding

Consider in-house compounding for PN orders provided the institution has the appropriate resources and staffing to prepare PN orders.6

Utilize P&Ps

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.

Using ACDs

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:

  • Only designated pharmacy staff should be permitted to make changes in the ACD database
  • Two staff members should use a physical checklist to perform the initial daily setup of the ACD
  • Utilize a signoff sheet or checklist when new products are added
  • The tubing set in the ACD should be traced from the source container to the port where the attachment is located

Manual Compounding

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.

Multiple Verifications

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

Safe Environment

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:

  • Verification procedures 
  • Infusion guidelines 
  • Termination of therapy 
  • Proper filtration
  • Osmolarity
  • Compatibility

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.


  1. Institute for Safe Medication Practices (ISMP). List of High Alert Medications; 2018. www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf. Accessed December 30, 2019.
  2. Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication related errors related to the parenteral nutrition process in a large university teaching hospital. Pharmacotherapy. 2009:29(8):966-974.
  3. Seres D, Sacks GS, Pedersen CA, et al. Parenteral nutrition safe practices: Results of the 2003 American Society for Parenteral and Enteral Nutrition Survey. JPEN J Parenter Enteral Nutr. 2006;30(3):259-265.
  4. Storey MA, Weber RJ, Besco K, et al. Evaluation of parenteral nutrition errors in an era of drug shortages. Nutr Clin Pract. 2016;31(2): 211-217.
  5. Mirtallo, JM. Parenteral nutrition: Can outcomes be improved? JPEN J Parenter Enteral Nutr. 2103;37(2):181-189.
  6. Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014;38(3):296-333.
  7. Shamliyan TA, Duval S, Du J, Kane RL. Just what the doctor ordered: review of the evidence of the impact of computerized physician order entry on medication errors. Health Serv Res. 2008;43(1):32-53.
  8. Institute for Safe Medication Practices (ISMP). Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors; 2012. www.ismp.org/resources/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry
  9. Institute for Safe Medication Practices (ISMP). Independent double checks: Undervalued and misused; 2013. www.ismp.org/resources/independent-double-checks-undervalued-and-misused-selective-use-strategy-can-play
  10. Durfee SM. Pharmacist specialty certification. JPEN J Parenter Enteral Nutr. 2012;36(2S):51S–52S.
  11. Rich DS, Fricker MP, Cohen MR, Levine SR. Guidelines for the safe preparation of sterile compounds: results of the ISMP sterile preparation compounding safety summit of October 2011. Hosp Pharm. 2013;48(4):282– 294.
  12. United States Pharmacopeia. USP chapter <797>; Pharmaceutical Compounding–Sterile Preparations. United States Pharmacopeia; 2006.
  13. Institute for Safe Medication Practices (ISMP). Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg; 2017. www.ismp.org/resources/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-and-mg
  14. Guenter P, Worthington P, Ayers P, et al. Standardized competencies for parenteral nutrition administration: The ASPEN model. Nutr Clin Pract. 2018;33(2):295-304.
  15. Boullata JI, Gilbert K, Sacks G, et al. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr. 2014;38(3):334-377.

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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