Mismatched Prescribing and Pharmacy Templates for Parenteral Nutrition (PN) Lead to Data Entry Errors

ISMP Medication Safety Alert 

In This Article

Problem

Parenteral nutrition (PN) is widely used to support the nutritional needs of patients of all ages, from low-birth-weight infants to elderly patients who are temporarily unable to meet nutritional goals due to an acute illness or following surgery. The benefits of PN are significant, but the potential for harm is great with this high-alert medication if it is used in error. Inappropriate dosing of nutrients, order entry errors, and compounding errors have all been associated with adverse outcomes and death. For example, in our April 21, 2011 newsletter, we discussed an error that resulted in the death of a 6-week-old infant who received 60 times more sodium than prescribed after a technician entered the prescribed dose of calcium ("982" mg) into the mEq field for sodium (www.ismp.org/newsletters/acutecare/articles/20110421.asp).

This month, we received another report of an order entry error. In this case, a physician prescribed PN for a 16-year-old boy who weighed 72 kg using a standard pediatric PN template in an electronic health record (EHR). This template prompted prescribers to order most of the ingredients in measurement units of g/kg, mEq/kg, or mmol/kg, using the patient's weight to calculate the daily amount of nutrients. Accordingly, the prescriber ordered the PN nutrients as g or mEq per kg in a total volume of 2,640 mL to infuse over 24 hours.

The pharmacy pediatric PN template was arranged similarly (dose of ingredients per kg) for patients weighing 40 kg or less; however, once the patient weighed more than 40 kg, the PN template required entry of all nutrients in measurement units of g/day, mEq/day, or mmol/day. The pharmacist who entered the PN order was still undergoing training in this area of the pharmacy. The pharmacist entered the order into the template for pediatric patients weighing more than 40 kg but failed to manually change the prescribed per kg doses to the corresponding total daily amounts. As a result, the errors listed in Table 1 (in the PDF version) were made while entering the PN order into the pharmacy PN template. The multivitamins and trace elements were prescribed and entered correctly as daily totals, as were the lipids.

After the PN order was entered, a trained technician prepared the solution using an automated compounding device. But he failed to notice that an unusually large amount of sterile water—more than 2,600 mL—was required to prepare the solution, even though a new bag of sterile water had to be hung during the compounding process. After the PN was mixed, another pharmacist checked the final preparation. All the numerical values matched the order, but the pharmacist failed to notice the incorrect units of measure and the very low total amounts of nutrients listed on the label. The patient's nurse also verified the PN label with the prescriber's order but failed to notice the errors. The patient received almost the entire bag of PN before the error was discovered the following day while preparing the next bag of solution.

After the correct PN solution was started, the erroneous solution was sent to the pharmacy for analysis. The osmolarity of the incorrectly compounded solution was found to be exceedingly hypotonic at 138 mOsm/L. Thankfully, the patient did not experience any adverse effects from the error. He continued receiving correctly compounded PN for several days and was later discharged from the hospital.

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