Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years

被引:34
作者
Guenter, Peggi [1 ]
Ayers, Phil [2 ]
Boullata, Joseph I. [3 ,4 ]
Gura, Kathleen M. [5 ]
Holcombe, Beverly [1 ]
Sacks, Gordon S. [6 ]
机构
[1] Amer Soc Parenteral & Enteral Nutr, 8630 Fenton St,Suite 412, Silver Spring, MD 20910 USA
[2] Baptist Hlth Syst, Clin Pharm Serv, Dept Pharm, Jackson, MS USA
[3] Hosp Univ Penn, Clin Nutr Support Serv, Philadelphia, PA 19104 USA
[4] Drexel Univ, Dept Nutr Sci, Philadelphia, PA 19104 USA
[5] Boston Childrens Hosp, Dept Pharm, Boston, MA USA
[6] Auburn Univ, Dept Pharm Practice, Auburn, AL 36849 USA
关键词
parenteral nutrition; safety; errors; medication errors; quality improvement; STANDARDIZED COMPETENCES; MEDICATION ERRORS; FREQUENCY; SEVERITY;
D O I
10.1177/0884533617715868
中图分类号
R15 [营养卫生、食品卫生]; TS201 [基础科学];
学科分类号
100403 ;
摘要
Parenteral nutrition (PN) is a complex, high-alert medication, and errors associated with the use of this therapy may lead to significant harm to patients. This document reviews error reports from the Institute for Safe Medication Practices' Medication Errors Reporting Program that are associated with the PN use process over the past 10 years. Actual PN-related errors are outlined, with most occurring in the PN-compounding/dispensing and PN administration steps. Clinicians involved in any phase of the PN use process should review their institutional or homecare company's processes for reporting of PN errors and collaborate with their medical safety officer and/or committees involved with medication error reporting.
引用
收藏
页码:826 / 830
页数:5
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