title: Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital.
abstract: OBJECTIVE
  To determine the frequency of medication errors, as well as the severity of harm resulting from these errors, related to the prescription, transcription, preparation, and administration of parenteral nutrition formulations.
  
  
  METHODS
  Prospective, observational study.
  
  
  METHODS
  471-bed, academic teaching hospital.
  
  
  METHODS
  All adult and pediatric inpatients receiving parenteral nutrition between November 1, 2002 and May 31, 2004.
  
  
  RESULTS
  The occurrence of incorrect prescribing practices, wrong formulation preparation, operational system errors, order entry errors related to automated technology, and incorrect administration practices were documented. In addition, the specific step in the drug process--prescription, transcription, preparation, and administration--at the time that the error occurred was noted. Harm scores, to assess the severity of the error in relation to the safety of the patient, were assigned based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The rate of errors with parenteral nutrition was then compared with the rate of errors with other high-alert drugs, both at our institution and at a health care consortium. A total of 4730 prescriptions for parenteral nutrition were written during the study period; 74 (1.6%) were associated with a medication error. Of these errors, 1 (1%) occurred during the prescription process (and was detected before preparation), 29 (39%) occurred during the transcription process, 18 (24%) during preparation, and 26 (35%) during the administration process. Sixty-seven (91%) of the 74 errors were considered nonharmful, as defined by NCC MERP, whereas 6 (8%) contributed to or resulted in temporary harm to a patient. The rate of errors was similar between our institution and the consortium, both for parenteral nutrition formulations and for other high-alert drugs. The overall incidence of medication errors during the study was 15.6 errors/1000 parenteral nutrition prescriptions compounded.
  
  
  CONCLUSIONS
  Our results demonstrate that medication errors related to the prescription, transcription, preparation, and administration of parenteral nutrition formulations occur and occasionally result in harm. Health care institutions should develop quality assurance programs to document compliance with published safe practice guidelines for parenteral nutrition.
authors.affiliation: Division of Pharmacy Practice, School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, USA. gss0005@auburn.edu
authors.forename: Gordon S
authors.initials: GS
authors.lastname: Sacks
authors.forename: Steve
authors.initials: S
authors.lastname: Rough
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Kudsk
mesh_terms: D006784:Hospitals, Teaching; D006801:Humans; D008508:Medication Errors / Q000009:adverse effects* / Q000706:statistics & numerical data*; D010288:Parenteral Nutrition / Q000706:statistics & numerical data*; D055553:Prescription Drugs; D011446:Prospective Studies
chemical_list: D055553:Prescription Drugs