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PARENTERAL NUTRITION: HOW TO PREVENT THE NEXT MISTAKE? (submitted in 2019)
European Statement
Patient Safety and Quality Assurance
Author(s)
saif salah
Why was it done?
In Carmel Medical Center, the infusion pack is delivered by a pharmacist according to the prescription given from PN staff, and afterwards the infusion instructions are recorded by one of the department physicians in the patient EHR. Recently there have been several mistakes that have been reported, which made it urgent to check matching between PN staff decision and the record of instructions in the EHR.
What was done?
Recognise the mismatch between the electronic health record (EHR) instructions for delivery of parenteral nutrition (PN), against the actual delivery by the pharmacy according to prescription from PN staff and characterisation of these cases in terms of mismatching.
How was it done?
Issuing a report of the PN doses delivered by the electronic system called “UNIT-DOSE” in the pharmacy according to the name of patient and days of treatment of 2018 vs. electronic instructions that have been recorded by one of the department physicians in the “Kamelyon” system or “Meta Vision ” The parameters examined were: type of solution, composition, volume, supplements-additives (electrolytes, vitamins, trace elements), infusion rate and method of infusion (central / peripheral). Infusion rate was examined separately as a follow-up by a nutritionist.
What has been achieved?
From our research, we found a significant difference between computerised recording of PN instructions and what the patient actually received. This is due to the separation between the hand-written prescription by the PN staff and the computerised instruction recording by the treatment team. This may constitute a danger to patients.
What next?
Examination and follow-up by the pharmacist is important for identifying and treating errors of this nature appropriately. Guidance sessions for the treating staff should be conducted in the different departments. The prescription must be matched by the PN staff to the computerised instruction by placing a prescription pattern. Set up protocols in the computerised system that guide the treatment staff in the department to record the correct instructions.