Parenteral Nutrition Safety

Limit ordering errors with PN.

• Advocate for use of an effective order entry/clinical decision support system interfaced with an automated compounder.^3,4
• Reduces risk associated with order re-entry or transcription.^2,4
• Use standardized order formats/templates, either computerized or electronic.^2,4
• Avoid handwritten orders and telephone or verbal orders.²
• Include full generic names of ingredients, and brand names only when needed for clarity (e.g., if multiple versions are available).²
• List electrolytes as complete salts (e.g., potassium chloride and potassium phosphate NOT potassium, chloride, and phosphate).²
• Use dosing unit of amount (e.g., grams, mEq, mmol) per day for adults or amount/kg/day for pediatrics or neonates.²
• Minimize free text on orders.⁶
• Ensure order of ingredients matches on orders and labels.^2,4
• If order transcription is needed, require an independent double check.²
• Require prescriber review of any order modifications.⁴

Compound PN accurately and safely.

• Advocate for automated, rather than manual, compounding processes.³
• Improves accuracy and efficiency and reduces contamination risk.
• Remedy environmental issues such as poor lighting, frequent interruptions, etc.²
• Use bar-code technology, such as for hanging and replacing products on the compounder.^3,4
• Trace tubing from the product to the compounder port when setting up or replacing products on the compounder.⁶
• Require pharmacist approval for any configuration or ingredient changes (e.g., due to product shortages) on the compounder.³
• Ensure any applicable changes in the EHR resulting from drug shortages are reflected in the compounder.³
• Keep vendor support contact information on-hand to reduce delays when there are compounder issues such as hardware or software malfunctions.³
• Properly address compounder warnings such as for dose, osmolarity, incompatibility (e.g., calcium/phosphate), malfunction (e.g., obstructed tubing).²
• Require pharmacist approval and independent double check for overrides.²
• Report situations that could lead to alert fatigue.⁴
• Stay alert for red flags for potential errors, such as a substantial change on a PN order from the previous day.^2,4
• If calculations or conversions are needed, require an independent double check.²
• Require independent double check of manual additives (i.e., additive container and syringe) before injection into PN bags.²
• Require comparison of labels to orders after compounding.²

Properly dispense PN.

• Assign appropriate beyond-use dates.
• PN bags with dextrose and protein or dextrose, protein, and fat should get a beyond-use date according to pharmacy policies, such as 24 hours from hang time.²
• Fat (i.e., lipid emulsion) alone should get a beyond-use date of 12 hours from hang time.²
• Ensure a 1.2 micron in-line filter is available for administration of PN.^2,5
• Check that this information is included on the PN label for nursing.²
• Mix any multichamber PN products prior to dispensing.²
• Observe PN bags for integrity and absence of issues (e.g., leaks or separation of fat from other components).²

Limit mishaps with premixed PN products.

• Streamline stock by routinely eliminating low-use products.
• Separate stock to prevent product selection errors.
• For example, Clinimix E products have added electrolytes compared with plain Clinimix products.
• For example,Kabiven has a higher dextrose concentration than Perikabiven, so Kabiven can only be infused centrally while Perikabiven can be infused centrally or peripherally.

Limit mishaps with outsourced PN.

• Advocate for interfacing EHR with outsourcer’s software for PN order transmission.⁴
• Reduces risk associated with order re-entry or transcription.^2,4
• Ensure processes are consistent regardless of whether PN is compounded in-house or by a third party.²
• For example, compare outsourced PN labels to orders prior to dispensing.²