Skip to main content
SpringerLink
Log in

Patient Safety Incidents Related to the Use of Parenteral Nutrition in All Patient Groups: A Systematic Scoping Review

  • Systematic Review
  • Published:
Drug Safety Aims and scope Submit manuscript

Abstract

Introduction

There is limited comprehensive literature focussing on the range of patient safety incidents related to parenteral nutrition (PN).

Objective

The aim of this review was to examine patient safety incidents related to the use of PN in all patient age groups.

Methods

Literature published in the English language between January 2000 and April 2020 were searched across the MEDLINE, CINHAL and Embase databases. Articles were included if they contained PN-related patient safety incidents related to an avoidable event. No restrictions were applied to patient populations. The screening process was undertaken independently by two authors.

Results

In total, 108 records were included in the review: 52 case studies, 54 observation studies (e.g. prevalence studies, surveys) and two experimental studies. All age groups were represented, with 62% of studies in paediatrics (of which two-thirds were neonates) and 23% in adults. They included all medication processes: prescribing, dispensing, compounding, administration and monitoring. Incidents were related to microbial contamination, venous access and specific components (e.g. lipid emulsion, amino acids, glucose, micronutrients and electrolytes) or the whole product. Incident outcomes ranging from near miss to death were reported. Intervention studies looked at the impact on patient safety incidents of computerised tools, healthcare processes, e.g. pharmacist screening, and standardisation. One study demonstrated more severe outcomes with paediatric than with adult PN.

Conclusions

This review demonstrates the vast range of PN-related patient safety incidents in all patient age groups and all medication process stages. The need for a national study looking at patient safety incidents related to PN in England is highlighted.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. National Institute for Health and Care Excellence. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical guideline [CG32]. 2006. https://www.nice.org.uk/guidance/cg32. Accessed 18 Apr 2020.

  2. National Confidential Enquiry into Patient Outcome and Death. A Mixed Bag. An enquiry into the care of hospital patients receiving parenteral nutrition. 2010. https://www.ncepod.org.uk/2010report1/downloads/PN_report.pdf. Accessed 18 Feb 2020.

  3. World Health Organization. Global patient safety challenge: medication without harm. 2017. http://apps.who.int/iris/bitstream/10665/255263/1/WHO-HIS-SDS-2017.6-eng.pdf?ua=1. Accessed 11 Nov 2019.

  4. World Health Organization. Medication safety in high-risk situations. Technical report. 2019. https://apps.who.int/iris/bitstream/handle/10665/325131/WHO-UHC-SDS-2019.10-eng.pdf?ua=1. Accessed 11 Nov 2019.

  5. Elliott R, Camacho E, Campbell F, Jankovic D, Martyn St James M, Kaltenthaler E et al. Prevalence and Economic Burden of Medication Errors in The NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Universities of Sheffield and York. 2018. http://www.eepru.org.uk/wp-content/uploads/2018/02/eepru-report-medication-error-feb-2018.pdf. Accessed 11 Nov 2019.

  6. Institute for Safe Medication Practices. ISMP list of high-alert medications in acute care settings. 2018. https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf. Accessed 20 Jan 2020.

  7. Mirtallo JM. Consensus of parenteral nutrition safety issues and recommendations. J Parenter Enteral Nutr. 2012;36(2 Suppl):62S. https://doi.org/10.1177/0148607111434782.

    Article  Google Scholar 

  8. Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. J Parenter Enteral Nutr. 2014;38(3):296–333. https://doi.org/10.1177/0148607113511992.

    Article  Google Scholar 

  9. Puntis J, Hojsak I, Ksiazyk J, ESPGHAN, ESPEN, ESPR, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: organisational aspects. Clin Nutr. 2018;37(6 Pt B):2392–400. https://doi.org/10.1016/j.clnu.2018.06.953.

    Article  PubMed  Google Scholar 

  10. NHS Improvement. Patient Safety Alert. Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. 2017. https://improvement.nhs.uk/documents/1756/Patient_Safety_Alert_-_TPN_in_babies_FINAL.pdf. Accessed 02 Dec 2019.

  11. NHS Improvement. Report a patient safety incident. 2017. https://improvement.nhs.uk/resources/report-patient-safety-incident/. Accessed 19 Jan 2020.

  12. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. https://doi.org/10.1080/1364557032000119616.

    Article  Google Scholar 

  13. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7): e1000097. https://doi.org/10.1371/journal.pmed.1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123(3):A12–3.

    Article  CAS  PubMed  Google Scholar 

  15. Moola S, Munn Z, Tufanaru C, Aromatari sE, Sears K, Sfetcu R et al. Chapter 7: Systematic reviews of etiology and risk In: JBI Manual for Evidence Synthesis. 2020. https://synthesismanual.jbi.global. Accessed 23 Oct 2020.

  16. Munn Z, Barker TH, Moola S, Tufanaru C, Stern C, McArthur A, et al. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth. 2020;18(10):2127–33. https://doi.org/10.11124/jbisrir-d-19-00099.

    Article  PubMed  Google Scholar 

  17. Munn Z, Moola S, Lisy K, Riitano D, Tufanaru C. Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. Int J Evid Based Healthc. 2015;13(3):147–53. https://doi.org/10.1097/xeb.0000000000000054.

    Article  PubMed  Google Scholar 

  18. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: systematic reviews of effectiveness. In: JBI manual for evidence synthesis. 2020. https://synthesismanual.jbi.global. Accessed 23 Oct 2020.

  19. Aveyard H, Payne S, Preston N. A post-graduate’s guide to doing a literature review. London: Open University Press; 2016.

    Google Scholar 

  20. Staes C, Jacobs J, Mayer J, Allen J. Description of outbreaks of health-care-associated infections related to compounding pharmacies, 2000–12. Am J Health Syst Pharm. 2013;70(15):1301–12. https://doi.org/10.2146/ajhp130049.

    Article  PubMed  Google Scholar 

  21. Arslan U, Erayman I, Kirdar S, Yuksekkaya S, Cimen O, Tuncer I, et al. Serratia marcescens sepsis outbreak in a neonatal intensive care unit. Pediatr Int. 2010;52(2):208–12. https://doi.org/10.1111/j.1442-200X.2009.02934.x.

    Article  PubMed  Google Scholar 

  22. Maltezou HC, Tryfinopoulou K, Katerelos P, Ftika L, Pappa O, Tseroni M, et al. Consecutive Serratia marcescens multiclone outbreaks in a neonatal intensive care unit. Am J Infect Control. 2012;40(7):637–42. https://doi.org/10.1016/j.ajic.2011.08.019.

    Article  PubMed  Google Scholar 

  23. Gehring S, Zepp F, Mildenberger E, Kampmann C, Pohlenz J, Huth RG. Contamination of parenteral nutrition solution causes severe endotoxemia/bacteremia in 11 children treated in a PICU/NICU. Pediatr Crit Care Med. 2011;12(3):A12.

    Google Scholar 

  24. Habsah H, Zeehaida M, Van Rostenberghe H, Noraida R, Wan Pauzi WI, Fatimah I, et al. An outbreak of Pantoea spp. in a neonatal intensive care unit secondary to contaminated parenteral nutrition. J Hosp Infect. 2005;61(3):213–8. https://doi.org/10.1016/j.jhin.2005.01.004.

    Article  CAS  PubMed  Google Scholar 

  25. Tresoldi AT, Padoveze MC, Trabasso P, Veiga JF, Marba ST, von Nowakonski A, et al. Enterobacter cloacae sepsis outbreak in a newborn unit caused by contaminated total parenteral nutrition solution. Am J Infect Control. 2000;28(3):258–61. https://doi.org/10.1067/mic.2000.105286.

    Article  CAS  PubMed  Google Scholar 

  26. Marais E, Stewart R, Dusé AG, Rosekilly IC, de Jong G, Aithma N. Candida parapsilosis detected in TPN using the BacT/Alert system and characterized by randomly amplified polymorphic DNA. J Hosp Infect. 2004;56(4):291–6. https://doi.org/10.1016/j.jhin.2004.01.014.

    Article  CAS  PubMed  Google Scholar 

  27. Al Nemri AM, Ignacio LC, Al Zamil FA, Al Jarallah AS. Rare but fatal complication of umbilical venous catheterization. Congenit Heart Dis. 2006;1(4):180–3. https://doi.org/10.1111/j.1747-0803.2006.00031.x.

    Article  PubMed  Google Scholar 

  28. Bekele NA, Abebe WA, Shifa JZ. Misplaced subclavian central venous catheter. Pan Afr Med J. 2017;27:59. https://doi.org/10.11604/pamj.2017.27.59.9532.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Booth SA, Norton B, Mulvey DA. Central venous catheterization and fatal cardiac tamponade. Br J Anaesth. 2001;87(2):298–302. https://doi.org/10.1093/bja/87.2.298.

    Article  CAS  PubMed  Google Scholar 

  30. dos Santos Modelli ME, Cavalcanti FB. Fatal cardiac tamponade associated with central venous catheter: a report of 2 cases diagnosed in autopsy. Am J Forensic Med Pathol. 2014;35(1):26–8. https://doi.org/10.1097/paf.0000000000000084.

    Article  PubMed  Google Scholar 

  31. Filan PM, Salek-Haddadi Y, Nolan I, Sharma B, Rennie JM. An under-recognised malposition of neonatal long lines. Eur J Pediatr. 2005;164(8):469–71. https://doi.org/10.1007/s00431-005-1667-2.

    Article  PubMed  Google Scholar 

  32. Stammet P, Werer C, Deridder F, Frambach P. Case report: delayed pleural effusion by femoral cooling catheter. Intensive Care Med. 2011;37(1):170–1. https://doi.org/10.1007/s00134-010-2028-9.

    Article  PubMed  Google Scholar 

  33. Warren M, Thompson KS, Popek EJ, Vogel H, Hicks J. Pericardial effusion and cardiac tamponade in neonates: sudden unexpected death associated with total parenteral nutrition via central venous catheterization. Ann Clin Lab Sci. 2013;43(2):163–71.

    PubMed  Google Scholar 

  34. Zasada IA, Banner J, Bugge A. “Nutrition or no nutrition?”: chylothorax or leakage of total parenteral nutrition? Forensic Sci Med Pathol. 2019;15(3):470–3. https://doi.org/10.1007/s12024-019-00113-6.

    Article  PubMed  Google Scholar 

  35. Cheah FC, Boo NY, Latif JY. An unusual case of refractory hypoglycaemia in a neonate receiving total parenteral nutrition. Acta Paediatr. 2000;89(4):497–8. https://doi.org/10.1080/080352500750028285.

    Article  CAS  PubMed  Google Scholar 

  36. Chen CC, Tsao PN, Yau KI. Paraplegia: complication of percutaneous central venous line malposition. Pediatr Neurol. 2001;24(1):65–8. https://doi.org/10.1016/s0887-8994(00)00222-8.

    Article  CAS  PubMed  Google Scholar 

  37. Knobel RB, Meetze W, Cummings J. Case report: total parenteral nutrition extravasation associated with spinal cord compression and necrosis. J Perinatol. 2001;21(1):68–71. https://doi.org/10.1038/sj.jp.7200473.

    Article  CAS  PubMed  Google Scholar 

  38. Kundra P, Chandran BV, Subbarao KS. Unanticipated complication of a malpositioned central venous catheter. J Anesth. 2009;23(2):275–7. https://doi.org/10.1007/s00540-008-0724-1.

    Article  PubMed  Google Scholar 

  39. McGlone L, O’Shea J, Granger C. Learning from neonatal clinical incidents: a rare complication of lower limb PICC insertion. Infant. 2018;14(5):184–5.

    Google Scholar 

  40. Pegu S, Murthy P. Ascites with hepatic extravasation of total parenteral nutrition (TPN) secondary to umbilical venous catheter (UVC) malposition in an extremely preterm baby. Br Med J Case Rep. 2018. https://doi.org/10.1136/bcr-2018-226377.

    Article  Google Scholar 

  41. Shareena I, Khu YS, Cheah FC. Intraperitoneal extravasation of total parental nutrition infusate from an umbilical venous catheter. Singapore Med J. 2008;49(2):e35–6.

    CAS  PubMed  Google Scholar 

  42. Cizmeci MN, Kanburoglu MK, Tatli MM. Extravasation and extra vigilance. J Vasc Access. 2013;14(2):201. https://doi.org/10.5301/jva.5000120.

    Article  PubMed  Google Scholar 

  43. Karch AM. Make the right connection: verify that tubing is correct. Am J Nurs. 2008;108(3):72. https://doi.org/10.1097/01.NAJ.0000312260.86990.d7.

    Article  PubMed  Google Scholar 

  44. Lonati D, Schicchi A, Petrolini VM, Chiara F, Buscaglia E, Sorrentino R, et al. Peridural accidental administration of xenobiotics: an unpredictable outcome. Clin Toxicol. 2016;54(4):448–9. https://doi.org/10.3109/15563650.2016.1165952.

    Article  Google Scholar 

  45. Blinc A, Sabovic M, Bozic M. Low-grade haemostatic activation and increased fibrin turnover due to a retained central venous guide wire, found accidentally after eight years. Thromb Haemost. 2006;96(6):852–3.

    CAS  PubMed  Google Scholar 

  46. Cohen MR, Smetzer JL. Important change with heparin labels; benadryl dispensed instead of vitamins for home parenteral nutrition; potassium and sodium acetate injection mix-ups; don’t truncate, stem, or shorten drug names. Hosp Pharm. 2013;48(4):267–9. https://doi.org/10.1310/hpj4804-267.

    Article  Google Scholar 

  47. Grissinger M. A fatal zinc overdose in a neonate: confusion of micrograms with milligrams. PT. 2011;36(7):393–409.

    Google Scholar 

  48. Ruktanonchai D, Lowe M, Norton SA, Garret T, Soghier L, Weiss E, et al. Zinc deficiency-associated dermatitis in infants during a nationwide shortage of injectable zinc—Washington, DC, and Houston, Texas, 2012–2013. Morb Mortal Wkly Rep. 2014;63(2):35–7.

    Google Scholar 

  49. Yusuf SW, Rehman Q, Casscells W. Cardiomyopathy in association with selenium deficiency: a case report. J Parenter Enteral Nutr. 2002;26(1):63–6. https://doi.org/10.1177/014860710202600163.

    Article  Google Scholar 

  50. Ali A, Walentik C, Mantych GJ, Sadiq HF, Keenan WJ, Noguchi A. Iatrogenic acute hypermagnesemia after total parenteral nutrition infusion mimicking septic shock syndrome: two case reports. Pediatr. 2003;112(1):e70–2. https://doi.org/10.1542/peds.112.1.e70.

    Article  Google Scholar 

  51. Brown EW, McClellan NH, Minard G, Maish GO 3rd, Dickerson RN. Avoiding patient harm with parenteral nutrition during electrolyte shortages. Hosp Pharm. 2018;53(6):403–7. https://doi.org/10.1177/0018578718769571.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Cohen MR, Smetzer JL. Another tragic parenteral nutrition compounding error: change in anzemet indication: Teva’s lansoprazole orally disentegrating tablet clogs tubes: lawyers weigh in on consistent use of smart pump libraries. Hosp Pharm. 2011;46(7):470–6. https://doi.org/10.1310/hpj4607-470.

    Article  Google Scholar 

  53. Grissinger M. Mismatched prescribing and pharmacy templates for parenteral nutrition lead to data-entry errors. PT. 2015;40(6):349–50.

    Google Scholar 

  54. Murphy MK, Gura KM, Tascione C, Carey AN, Duggan CP, Raphael BP. Home parenteral nutrition and intravenous fluid errors discovered through novel clinical practice of reconciling compounding records: a case series. Nutr Clin Pract. 2017;32(6):820–5. https://doi.org/10.1177/0884533617722759.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Vecchione A. Johns Hopkins settles fatal medication error lawsuit. Drug Topics. 2004;148(6):HSE27.

    Google Scholar 

  56. Lin KK, Lee JJ, Chen HC. Severe refeeding hypophosphatemia in a CAPD patient: a case report. Ren Fail. 2006;28(6):515–7. https://doi.org/10.1080/08860220600767228.

    Article  PubMed  Google Scholar 

  57. Tomita T, Goto H, Sumiya K, Yoshida T, Tanaka K, Kohda Y. Stabilization of the serum lithium concentration by regulation of sodium chloride intake: case report. Yakugaku Zasshi. 2016;136(3):517–21. https://doi.org/10.1248/yakushi.15-00256.

    Article  CAS  PubMed  Google Scholar 

  58. Anderson C, Stidham C, Boehme S, Cash J. Avoidance of overt precipitation and patient harm following errant Y-site administration of calcium chloride and parenteral nutrition compounded with sodium glycerophosphate. Nutr Clin Pract. 2018;33(6):902–5. https://doi.org/10.1177/0884533617723865.

    Article  CAS  PubMed  Google Scholar 

  59. Bora KM, Hedge MW. Neonatal triglyceride levels after massive lipid bolus—implications for lipid rescue. Clin Toxicol. 2009;47(7):760. https://doi.org/10.1080/15563650903076924.

    Article  Google Scholar 

  60. Hoofien A, Mozer Y, Guz-Mark A, Hoffer V, Landau D, Shamir R. Inadvertent rapid lipid emulsion administration. Isr Med Assoc J. 2019;21(2):129–30.

    PubMed  Google Scholar 

  61. Katzenberger ME, Cole JB, Laes JR, Bangh SA. Hypoxia and dyspnea immediately following unitentional rapid infusion of ILE. Clin Toxicol. 2014;52(7):756–7.

    Google Scholar 

  62. Khasawneh W, Bani HS. Intravenous lipid emulsion overdose in infancy: a case report and overview of opportunities, challenges and prevention. Drug Saf Case Rep. 2018;5(1):13. https://doi.org/10.1007/s40800-018-0079-y.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Lodeserto F, Al-Jaghbeer M, Huang D. Accidental bolus of parenteral nutrition. J Parenter Enteral Nutr. 2016;40(6):883–5. https://doi.org/10.1177/0148607115572194.

    Article  CAS  Google Scholar 

  64. Low E, Ryan CA. Overdose of intravenous intralipid in a premature neonate. Jt Comm J Qual Patient Saf. 2007;33(10):588–9. https://doi.org/10.1016/s1553-7250(07)33064-x.

    Article  PubMed  Google Scholar 

  65. Cohen MR. Ensure proper mixing of dual-chamber bags; do recruiters and telemarketers contribute to dispensing errors?; Wrong dose recognized, not returned, and eventually administered; pediatric medication error prevention guidelines published by ISMP and PPAG; nonproprietary names also involved in errors. Hosp Pharm. 2002;37(9):911–1000. https://doi.org/10.1177/001857870203700910.

    Article  Google Scholar 

  66. Cohen MR. Action needed to prevent dangerous heparin-insulin confusion; sorting things out; staff unaware of fentanyl patch starting doses. Hosp Pharm. 2007;42(8):675–9. https://doi.org/10.1310/hpj4208-675.

    Article  Google Scholar 

  67. Grissinger M. “Smart” infusion pumps join CPOE and bar coding as way to prevent medication errors. PT. 2006;31(10):562.

    Google Scholar 

  68. Adams A, Wegner E. The effect of total parenteral nutrition (TPN) on glomerular filtration rate (GFR) measurement. Int Med J. 2011;41(3):23.

    Google Scholar 

  69. Binkley JF, Mills B, Roy MA, Diaz JJ, Jensen GL. Spurious laboratory values from improper sampling of blood containing parenteral nutrition. Nutr Clin Pract. 2004;19(5):540–1. https://doi.org/10.1177/0115426504019005540.

    Article  PubMed  Google Scholar 

  70. Nolli M, Barbieri A, Pinna C, Pasetto A, Nicosia F. Wernicke’s encephalopathy in a malnourished surgical patient: clinical features and magnetic resonance imaging. Acta Anaesthesiol Scand. 2005;49(10):1566–70. https://doi.org/10.1111/j.1399-6576.2005.00879.x.

    Article  CAS  PubMed  Google Scholar 

  71. Solmaz S, Gereklioğlu Ç, Tan M, Demir Ş, Yeral M, Korur A, et al. A rare complication developing after hematopoietic stem cell transplantation: Wernicke’s encephalopathy. Turk J Haematol. 2015;32(4):367–70. https://doi.org/10.4274/tjh.2014.0412.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  72. Almendral Vicente MAA, Alcalá Soto A, Jimenez TJ. Technology and technique to detect errors in parenteral nutrition prescription. Clin Nutr. 2018;37:S255. https://doi.org/10.1016/j.clnu.2018.06.1901.

    Article  Google Scholar 

  73. Ameer A, Taberner-Stokes A, Dhillon S, Booth R, Peters M, Ghaleb M. Retrospective analysis of medicine related critical incident reports in paediatric intensive care unit. Intensive Care Med. 2013;39(1):S62. https://doi.org/10.1007/s00134-013-2950-8.

    Article  Google Scholar 

  74. Angelstorf I, Gryllaki-Berger M, Palmero D, Fischer-Fumeaux C, Sadeghipour F. PP-027 Evaluation of the quality of the parenteral nutrition prepared on the neonatology ward. Eur J Hosp Pharm. 2016;23(Suppl 1):A-206-A. https://doi.org/10.1136/ejhpharm-2016-000875.466.

    Article  Google Scholar 

  75. Carpentier I, Gaboriau L, Gras-Champel V, Yilmaz M, Bene J. One year of never events in Hauts-De-France Region, France. Fundam Clin Pharmacol. 2019;33(S1):84. https://doi.org/10.1111/fcp.12470.

    Article  Google Scholar 

  76. Cole C, Robertson S. Nine cases of unintentional rapid infusion of lipid emulsion in children: root cause analysis and changes to practice. Arch Dis Child. 2014;99:e3.

    Article  Google Scholar 

  77. Dolores TGM, Dolores SRM, Isabel STM, Aitana RP, Concepcion ADVB, Victoria GNM. Medication error reported in a hospital: Severity and improvement plans. Int J Clin Pharm. 2015;37(1):242. https://doi.org/10.1007/s11096-014-0039-2.

    Article  Google Scholar 

  78. Pietka M, Stepska D, Szczepanek K, Klek S. PP214-MON: identifying errors in parenteral nutrition (PN) orders. Clin Nutr. 2014;33:S208. https://doi.org/10.1016/S0261-5614(14)50548-1.

    Article  Google Scholar 

  79. Stuttaford L, Chakraborty M, Carson-Stevens A, Powell C. Patient safety incidents in neonatology: a 10-year descriptive analysis of reports from NHS England and Wales. Arch Dis Children. 2018;103(Suppl 1):A78.

    Google Scholar 

  80. Cowley E, Williams R, Cousins D. Medication errors in children: a descriptive summary of medication error reports submitted to the United States pharmacopeia. Curr Ther Res Clin Exp. 2001;62(9):627–40. https://doi.org/10.1016/S0011-393X(01)80069-2.

    Article  Google Scholar 

  81. Hicks RW, Becker SC, Chuo J. A summary of NICU fat emulsion medication errors and nursing services: data from MEDMARX. Adv Neonatal Care. 2007;7(6):299–308. https://doi.org/10.1097/01.Anc.0000304969.23837.95 (quiz 9–10).

    Article  PubMed  Google Scholar 

  82. Narula P, Hartigan D, Puntis JWL. The frequency and importance of reported errors related to parenteral nutrition in a regional paediatric centre. e-SPEN Eur J Clin Nutr Metab. 2011;6:e131–4. https://doi.org/10.1016/j.eclnm.2011.02.005.

    Article  Google Scholar 

  83. Raphael BP, Murphy MK, Gura KM, Litman H, Dalton MK, Finkelstein JA, et al. Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions. Nutr Clin Pract. 2016;31(5):654–8. https://doi.org/10.1177/0884533616639410.

    Article  PubMed  Google Scholar 

  84. Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital. Pharmacotherapy. 2009;29(8):966–74. https://doi.org/10.1592/phco.29.8.966.

    Article  PubMed  Google Scholar 

  85. Storey MA, Weber RJ, Besco K, Beatty S, Aizawa K, Mirtallo JM. Evaluation of parenteral nutrition errors in an era of drug shortages. Nutr Clin Pract. 2016;31(2):211–7. https://doi.org/10.1177/0884533615608820.

    Article  CAS  PubMed  Google Scholar 

  86. National Coordinating Council for Medication Error Reporting and Prevention. Index for Categorizing Medication Errors. 2001. https://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf. Accessed 11 Nov 2019.

  87. Snijders C, van Lingen RA, Klip H, Fetter WP, van der Schaaf TW, Molendijk HA. Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. Arch Dis Child Fetal and Neonatal Ed. 2009;94(3):F210–5. https://doi.org/10.1136/adc.2007.135020.

    Article  CAS  Google Scholar 

  88. de Burgoa LJ, Seidner D, Hamilton C, Stafford J, Steiger E. Examination of factors that lead to complications for new home parenteral nutrition patients. J Infus Nurs. 2006;29(2):74–80. https://doi.org/10.1097/00129804-200603000-00004.

    Article  PubMed  Google Scholar 

  89. Guenter P, Ayers P, Boullata JI, Gura KM, Holcombe B, Sacks GS. Parenteral nutrition errors and potential errors reported over the past 10 years. Nutr Clin Pract. 2017;32(6):826–30. https://doi.org/10.1177/0884533617715868.

    Article  PubMed  Google Scholar 

  90. Bateman R, Donyai P. Errors associated with the preparation of aseptic products in UK hospital pharmacies: lessons from the national aseptic error reporting scheme. Qual Saf Health Care. 2010;19(5): e29. https://doi.org/10.1136/qshc.2009.034751.

    Article  PubMed  Google Scholar 

  91. Ding Q, Barker KN, Flynn EA, Westrick SC, Chang M, Thomas RE, et al. Incidence of intravenous medication errors in a Chinese hospital. Value Health Reg Issues. 2015;6:33–9. https://doi.org/10.1016/j.vhri.2015.03.004.

    Article  PubMed  Google Scholar 

  92. Boullata JI, Guenter P, Mirtallo JM. A parenteral nutrition use survey with gap analysis. J Parenter Enteral Nutr. 2013;37(2):212–22. https://doi.org/10.1177/0148607112464781.

    Article  Google Scholar 

  93. Seres D, Sacks GS, Pedersen CA, Canada TW, Johnson D, Kumpf V, et al. Parenteral nutrition safe practices: results of the 2003 American Society for Parenteral and Enteral Nutrition survey. J Parenter Enteral Nutr. 2006;30(3):259–65. https://doi.org/10.1177/0148607106030003259.

    Article  Google Scholar 

  94. Porcelli P. A survey of neonatal parenteral nutrition design practices in North Carolina. J Perinato. 2004;24(3):137–42. https://doi.org/10.1038/sj.jp.7210991.

    Article  Google Scholar 

  95. Calixto L, Mirco A, Falcão F. 5PSQ-116 Identification of high-alert medication for paediatric patients in a central hospital. Eur J Hosp Pharm. 2018;25(Suppl 1):A218-A. https://doi.org/10.1136/ejhpharm-2018-eahpconf.469.

    Article  Google Scholar 

  96. Franke HA, Woods DM, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Critical Care Med. 2009;10(1):85–90. https://doi.org/10.1097/PCC.0b013e3181936ff8.

    Article  Google Scholar 

  97. Mrayyan MT. Reported incidence, causes, and reporting of medication errors in teaching hospitals in Jordan: a comparative study. Contemp Nurse. 2012;41(2):216–32. https://doi.org/10.5172/conu.2012.41.2.216.

    Article  PubMed  Google Scholar 

  98. Hollingsworth C, Clarke P, Sharma A, Upton M. National survey of umbilical venous catheterisation practices in the wake of two deaths. Arch Dis Child Fetal Neonatal Ed. 2015;100(4):F371–2. https://doi.org/10.1136/archdischild-2015-308327.

    Article  PubMed  Google Scholar 

  99. Bahrami M, Jazayeri SH, Soltani F, Rashidi M, Azizi-soleiman F. Impact of dietitians in errors associated to parenteral nutrition prescription. Indian J Public Health Res Dev. 2018;9:271.

    Article  Google Scholar 

  100. Berlana D, Almendral MA, Abad MR, Fernández A, Torralba A, Cervera-Peris M, et al. Cost, time, and error assessment during preparation of parenteral nutrition: multichamber bags versus hospital-compounded bags. J Parenter Enteral Nutr. 2019;43(4):557–65. https://doi.org/10.1002/jpen.1436.

    Article  Google Scholar 

  101. Horn W, Popow C, Miksch S, Kirchner L, Seyfang A. Development and evaluation of VIE-PNN, a knowledge-based system for calculating the parenteral nutrition of newborn infants. Artif Intell Med. 2002;24(3):217–28. https://doi.org/10.1016/s0933-3657(01)00105-1.

    Article  PubMed  Google Scholar 

  102. Broome L, Cox SJ, Crill CM. Frequency and severity of errors related to neonatal and pediatric parenteral nutrition. Pharmacother. 2012;32(10): e270. https://doi.org/10.1002/j.1875-9114.2012.01219.

    Article  Google Scholar 

  103. Brown CL, Garrison NA, Hutchison AA. Error reduction when prescribing neonatal parenteral nutrition. Am J Perinatol. 2007;24(7):417–27. https://doi.org/10.1055/s-2007-984404.

    Article  PubMed  Google Scholar 

  104. Crews J, Rueda-de-Leon E, Remus D, Sayles R, Mateus J, Shakeel F. Total parenteral nutrition standardization and electronic ordering to reduce errors: a quality improvement initiative. Pediatr Qual Saf. 2018;3(4): e093. https://doi.org/10.1097/pq9.0000000000000093.

    Article  PubMed  PubMed Central  Google Scholar 

  105. Hilmas E, Partyka CM. Implementation of computerized parenteral nutrition orders in a community pediatric hospital. Am J Health Syst Pharm. 2004;61(3):273–7.

    Article  PubMed  Google Scholar 

  106. Huston RK, Markell AM, McCulley EA, Marcus MJ, Cohen HS. Computer programming: quality and safety for neonatal parenteral nutrition orders. Nutr Clin Pract. 2013;28(4):515–21. https://doi.org/10.1177/0884533613490741.

    Article  PubMed  Google Scholar 

  107. Lehmann CU, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator. Pediatr. 2004;113(4):748–53.

    Article  Google Scholar 

  108. Li Q, Kirkendall ES, Hall ES, Ni Y, Lingren T, Kaiser M, et al. Automated detection of medication administration errors in neonatal intensive care. J Biomed Inform. 2015;57:124–33. https://doi.org/10.1016/j.jbi.2015.07.012.

    Article  PubMed  PubMed Central  Google Scholar 

  109. MacKay M, Anderson C, Boehme S, Cash J, Zobell J. Frequency and severity of parenteral nutrition medication errors at a large children’s hospital after implementation of electronic ordering and compounding. Nutr Clin Pract. 2016;31(2):195–206. https://doi.org/10.1177/0884533615591606.

    Article  CAS  PubMed  Google Scholar 

  110. Mulherin DW, Mulherin DP, Kumpf V, Hale J, Murphree JN, Alrifai MW. Evaluation of standards-driven clinical decision support effects on improving safety of parenteral nutrition orders in a computerized provider order entry system. J Parenter Enteral Nutr. 2017;41(2):288. https://doi.org/10.1177/0148607116686023.

    Article  Google Scholar 

  111. Skouroliakou M, Konstantinou D, Papasarantopoulos P, Matthaiou C. Computer assisted total parenteral nutrition for pre-term and sick term neonates. Pharm World Sci. 2005;27(4):305–10. https://doi.org/10.1007/s11096-005-2462-x.

    Article  PubMed  Google Scholar 

  112. Arumugam V, Arunan SK, Balasubramanian GP, Paruchuri S. A prospective study on medication and total parenteral nutrition practices at a neonatal intensive care unit. Arch Pharm Pract. 2016;7(4):142–8. https://doi.org/10.4103/2045-080X.191930.

    Article  Google Scholar 

  113. Cayón-Blanco M, García-Figueras-Mateos C, Almendral-Vicente MA, García-García-Doncel L. Cross check strategy to improve the safety of parenteral nutrition. Clin Nutr. 2018;37:S138–9. https://doi.org/10.1016/j.clnu.2018.06.1514.

    Article  Google Scholar 

  114. Garg M, Swab M, Gibney D, Cohen J, Gupta N, Ooi CY. Influence of dietitians in preventing parenteral nutrition prescription errors in children. J Parenter Enteral Nutr. 2018;42(3):607–12. https://doi.org/10.1177/0148607117697935.

    Article  Google Scholar 

  115. Hazem S, Gomaa MK, Rashid K, Zaitoun M. Pharmacist-conducted review prevents potential prescribing errors of neonatal parenteral nutrition: a cross sectional study. Pharmacoepidemiol Drug Saf. 2019;28(S2):179–80. https://doi.org/10.1002/pds.4864.

    Article  Google Scholar 

  116. Hermanspann T, Schoberer M, Robel-Tillig E, Hartel C, Goelz R, Orlikowsky T, et al. Incidence and severity of prescribing errors in parenteral nutrition for pediatric inpatients at a neonatal and pediatric intensive care unit. Front Pediatr. 2017;5:149. https://doi.org/10.3389/fped.2017.00149.

    Article  PubMed  PubMed Central  Google Scholar 

  117. Lustig A. Medication error prevention by pharmacists–an Israeli solution. Pharm World Sci. 2000;22(1):21–5. https://doi.org/10.1023/a:1008774206261.

    Article  CAS  PubMed  Google Scholar 

  118. Teoh SWK, Hattingh L, Lebedevs T, Parsons R. Analysis of clinical intervention records by pharmacists in an Australian principal referral and specialist women’s and newborns’ hospital. J Pharm Pract Res. 2017;47(4):277–86. https://doi.org/10.1002/jppr.1241.

    Article  Google Scholar 

  119. Valera Rubio M, Gómez Delgado M, Puerto Morlán A, Estaun C, Moya-Carmona I, Fernández OJ. 4CPS-218 Assessment of clinical pharmacist interventions in an intensive care unit. Eur J Hosp Pharm. 2019;26(Suppl 1):A171-A. https://doi.org/10.1136/ejhpharm-2019-eahpconf.367.

    Article  Google Scholar 

  120. Valério C, Valongo S, Homem de Mello S, Palma D. CP-128 Assessment of error and pharmaceutical intervention in parenteral nutrition prescribing in neonatology. Eur J Hosp Pharm. 2015;22(Suppl 1):A51-A. https://doi.org/10.1136/ejhpharm-2015-000639.122.

    Article  Google Scholar 

  121. Yailian AL, Revel E, Tardy C, Fontana A, Estublier C, Decullier E, et al. Assessment of the clinical relevance of pharmacists’ interventions performed during medication review in a rheumatology ward. Eur J Intern Med. 2019;59:91–6. https://doi.org/10.1016/j.ejim.2018.08.017.

    Article  PubMed  Google Scholar 

  122. Najem H. CP-047 evaluation of the clinical pharmacist impact on total parenteral nutrition prescription order review and preparation in the neonatal intensive care unit. Eur J Hosp Pharm. 2017;24(Suppl 1):A21. https://doi.org/10.1136/ejhpharm-2017-000640.46.

    Article  Google Scholar 

  123. Poh BY, Benajmin S, Hayward TZ 3rd. Standardized hospital compounded parenteral nutrition formulations do not guarantee safety. Am Surg. 2011;77(6):e109–11.

    Article  PubMed  Google Scholar 

  124. Howlett K, Ford J. Obtaining accurate blood sampling from a central line during total parenteral nutrition administration: multidisciplinary team approach. Oncol Nurs Forum. 2009;36(3):69.

    Google Scholar 

  125. Mohamed MW, Smith J-A, Nelson S, Casas K, Altaf W. Reduction in newborn screening false positive results in the Nicu: a quality improvement project. Pediatr. 2018;141(1 MeetingAbstract):554. https://doi.org/10.1542/peds.141.1_MeetingAbstract.554.

    Article  Google Scholar 

  126. Fairholm L, Saqui O, Baun M, Yeung M, Fernandes G, Allard JP. Monitoring parenteral nutrition in hospitalized patients: issues related to spurious bloodwork. Nutr Clin Pract. 2011;26(6):700–7. https://doi.org/10.1177/0884533611427041.

    Article  PubMed  Google Scholar 

  127. Morris M, Fischer K, Leydiker K, Elliott L, Newby J, Abdenur JE. Reduction in newborn screening metabolic false-positive results following a new collection protocol. Genet Med. 2014;16(6):477–83. https://doi.org/10.1038/gim.2013.171.

    Article  PubMed  Google Scholar 

  128. Tim-Aroon T, Harmon HM, Nock ML, Viswanathan SK, McCandless SE. Stopping parenteral nutrition for 3 hours reduces false positives in newborn screening. J Pediatr. 2015;167(2):312–6. https://doi.org/10.1016/j.jpeds.2015.04.063.

    Article  PubMed  Google Scholar 

  129. Elia M. Artificial nutritional support in clinical practice in Britain. J R Coll Physicians Lond. 1993;27(1):8–15.

    CAS  PubMed  PubMed Central  Google Scholar 

  130. Nightingale J. Nutrition support teams: how they work, are set up and maintained. Frontline Gastroenterol. 2010;1(3):171–7. https://doi.org/10.1136/fg.2009.000224.

    Article  PubMed  PubMed Central  Google Scholar 

  131. Ayers P, Foster J, Kanorwala A, Jenkins A, Raymer K, Byrd L, et al. Electronic health record and parenteral nutrition functionality: a gap analysis. Nutr Clin Pract. 2020. https://doi.org/10.1002/ncp.10463.

    Article  PubMed  Google Scholar 

  132. Ahmed Z, Garfield S, Jani Y, Jheeta S, Franklin BD. Impact of electronic prescribing on patient safety in hospitals: implications for the UK. Clin Pharm. 2016. https://doi.org/10.1211/CP.2016.20201013.

    Article  Google Scholar 

  133. NHS Improvement. Pharmacy Aseptic Services Review. Summary of Key Findings. 2018. https://www.sps.nhs.uk/wp-content/uploads/2018/04/NHSI-Aseptic-Summary-and-Findings_280318.pdf. Accessed 31 Oct 2020.

  134. Department of Health & Social Care. Transforming NHS Pharmacy Aseptic Services in England. 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/931195/aseptic-pharmacy.pdf. Accessed 31 Oct 2020.

  135. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28(4):365–77. https://doi.org/10.1016/j.clnu.2009.03.015.

    Article  PubMed  Google Scholar 

  136. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. J Am Med Assoc. 2001;285(16):2114–20. https://doi.org/10.1001/jama.285.16.2114.

    Article  CAS  Google Scholar 

  137. Williams SD, Ashcroft DM. Medication errors: how reliable are the severity ratings reported to the national reporting and learning system? Int J Qual Health Care. 2009;21(5):316–20. https://doi.org/10.1093/intqhc/mzp034.

    Article  PubMed  Google Scholar 

  138. Torjesen I. Parenteral nutrition product is suspected as cause of 18 cases of septicaemia in neonates. Br Med J. 2014;348: g3763. https://doi.org/10.1136/bmj.g3763.

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank the University of Southampton Health Sciences Library specialists and Angela Badiani, Medicines Advice service at the University Hospital Southampton NHS Foundation Trust, for their advice and contribution to the search strategy. We also thank Dr Emily Smith, Pharmacy Research Fellow at the University Hospital Southampton NHS Foundation Trust, for guidance during study set-up.

Author information

Authors and Affiliations

  1. Pharmacy Department, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK

    Priya Mistry & Andy Fox

  2. Gastroenterology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK

    Rebecca Heather Smith

Authors
  1. Priya Mistry
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rebecca Heather Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andy Fox
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Priya Mistry.

Ethics declarations

Funding

No sources of financial assistance were used to conduct the study.

Conflicts of interest

PM, RHS and AF have no conflicts of interest that might be relevant to the contents of this manuscript.

Ethics approval

NHS Research Ethics Committee approval was not required for this literature review.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and material

All data generated and analysed during this study are included in this publication.

Code availability

Not applicable.

Author contributions

PM and AF contributed to the study conception and design. PM completed the database searches. PM, RHS and AF completed the study selection process. Systematic review planning and data analysis was led by PM and supported by AF. PM drafted the manuscript. RHS and AF commented on previous versions. All authors read and approved the final manuscript.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 731 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mistry, P., Smith, R.H. & Fox, A. Patient Safety Incidents Related to the Use of Parenteral Nutrition in All Patient Groups: A Systematic Scoping Review. Drug Saf 45, 1–18 (2022). https://doi.org/10.1007/s40264-021-01134-3

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40264-021-01134-3

Search

Navigation