(P03-017-24) Enhancing Patient Safety in Delivering Parenteral Nutrition: Insights From Pharmacy Alerts and Interventions

Objectives: Parenteral Nutrition (PN) is designated “High Alert” by the Institute for Safe Medication Practices (elevated risk of harm due to error). Herein we report errors in PN ordering by our high-volume specialist team at a tertiary medical center, as identified by alerts issued by our PN pharmacists.

Methods: A retrospective review of errors related to adult PN orders, extracted from the secure chat system in our EMR, from January 5^th through February 5^th, 2024.

Results: The most prevalent alerts were categorized as errors in adjusting macronutrients, electrolytes, calcium, insulin, thiamine, multivitamins, as well as calcium-phosphate solubility, PN compatibility with medications, missed up-trending liver enzymes, inaccurate laboratory results/contamination of specimen, and missing orders for patients known to be receiving PN. Less frequent alerts included: orders placed by non-credentialed provider, mismatch between orders and compounding, missing allergy information, and filter size. Interventions implemented in response included order adjustment, notification of relevant teams or compounding pharmacy, withholding PN, placing missing orders, or no intervention.

During the 32-day period, 602 PN orders (mean ~19 per day) were placed. In this period, we count 126 errors. Of total errors, distribution of error type was (% rounded): missing orders 32%, macronutrients 14%, electrolytes10%, calcium10%, insulin 7%, thiamine 7%, increasing liver enzymes levels 4%, vitamin dosing 4%, calcium phosphate solubility 2%, medication/PN incompatibility 2%, inaccurate laboratory results 2%, filter size 1.5% and orders placed by non-credentialed provider, mismatched order, or missing allergy information < 1% each. Interventions include: no intervention 41.3%, order adjustment 31%, placement of missing orders 15%, and team notified to repeat labs, replete electrolytes, etc. 12%. To our knowledge, no adverse clinical events resulted from any of these.

Conclusions: Despite specialized training, intelligent order entry, adherence to published safe practices including quiet ordering environment, and high level of experience, errors were frequent, highlighting the importance of a multidisciplinary approach to PN ordering. This pilot will serve to inform a more extensive planned review.

Funding Sources: None