0148-6071/06/3003-0259$03.00/0 Vol. 30, No.

3
JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Printed in U.S.A.
Copyright © 2006 by the American Society for Parenteral and Enteral Nutrition

Special Report

Parenteral Nutrition Safe Practices: Results of the 2003 American

Society for Parenteral and Enteral Nutrition Survey*

David Seres, MD, CNSP*; Gordon S. Sacks, PharmD, BCNSP†; Craig A. Pedersen, RPh, PhD, FAPhA‡;
Todd W. Canada, PharmD, BCNSP§; Deborah Johnson, MS, RN储; Vanessa Kumpf, PharmD, BCNSP¶;
Peggi Guenter, PhD, RN, CNSN#; Craig Petersen, RD, CNSD**; and Jay Mirtallo, MS, RPh, BCNSP††

From the *Beth Israel Medical Center and Albert Einstein College of Medicine, New York, New York; †School of Pharmacy, University of Wisconsin,
Madison, Wisconsin; ‡College of Pharmacy, Ohio State University, Columbus, Ohio; §The University of Texas MD Anderson Cancer Center, Houston,
Texas; 储Meriter Hospital, Madison, Wisconsin; ¶Nutrishare, Inc, Elk Grove, California; #A.S.P.E.N., Silver Spring, Maryland; **University of
California Davis Medical Center, Sacramento, California; and the ††The Ohio State University Medical Center, Columbus, Ohio

ABSTRACT. Background: The American Society for Paren-
teral and Enteral Nutrition (A.S.P.E.N.) recently published a
revision of its “Safe Practices for Parenteral Nutrition” guide-
lines. Because there is a paucity of published scientific evi-
dence to support good practices related to ordering, com-
pounding, and administering parenteral nutrition (PN), a
survey was performed in the process of the revision to gain
insight into the discrepancies between reported practices and
previous guidelines. Methods: A web-based survey consisting
of 45 questions was conducted (n ⫽ 651) June 1–30, 2003.
Respondents were queried about primary practice setting,
professional background, processes for writing PN orders,
computer order entry of PN orders, problems with PN orders,
and adverse events related to PN. Results: There were 651
survey responses, 90% of which were from hospital-based
practitioners. Almost 75% of responders processed between
0 and 20 PN orders per day. Overall, physicians (78%) were
responsible for writing PN orders, but dietitians and phar-
macists had significant involvement. PN base components
were most often ordered as percentage final concentration
after admixture (eg, 20% dextrose), which is inconsistent
with safe practice guidelines of ordering by total amount per
day (eg, 200 g/day). There was no consistent method for
ordering PN electrolytes. Approximately 45% of responders
reported adverse events directly related to PN that required
intervention. Of these events, 25% caused temporary or per-
manent harm, and 4.8% resulted in a near-death event or
death. Conclusions: Although the survey found consistency in
PN practices for many areas queried, significant variation
exists in the manner by which PN is ordered and labeled.
( Journal of Parenteral and Enteral Nutrition 30:259 –265, 2006)

As part of its mission to serve as the preeminent,
interdisciplinary nutrition society dedicated to patient-
centered, clinical practice worldwide through advo-
cacy, education, and research in specialized nutrition
support, the American Society for Parenteral and
Enteral Nutrition (A.S.P.E.N.) published “Safe Prac-
tices for Parenteral Nutrition.” 1 This document pro-
vides guidelines with supporting evidence to foster
quality parenteral nutrition (PN) therapy. The intent
is for the principles provided in the document to
become incorporated into healthcare organization
practice for the purpose of minimizing the risks of PN
complications.
“Safe Practices for Parenteral Nutrition” was exten-
sively revised, adding a new section on the PN ordering
process and significantly expanding the section
devoted to PN administration.2 Unfortunately, there is
Received for publication August 25, 2005.
Accepted for publication February 6, 2006.
Correspondence: Gordon S. Sacks, PharmD, BCNSP, 777 Highland
Avenue, University of Wisconsin–Madison, Madison, WI 53705.
Electronic mail may be sent to gssacks@pharmacy.wisc.edu.
Results presented in part at Nutrition Week Meeting of the Ameri-
can Society for Parenteral and Enteral Nutrition, Orlando, Florida,
February, 2005.
little, if any, published evidence to support good prac-
tices in these areas. Although data from randomized
clinical trials of nutrition support are ideal for devel-
oping clinical practice guidelines, this type of informa-
tion is not widely available. Several factors inherently
limit the use of prospective randomized clinical trials
in the evaluation of nutrition support.3 Those most
likely to benefit from the treatment (eg, severely mal-
nourished patients) cannot be randomized to an unfed
control group due to ethical dilemmas. Other limita-
tions include outcome results influenced by clinical
variables independent of nutrition support and inabil-
ity to recruit large numbers of eligible individuals from
1 medical center, contributing to the enrollment of
marginal candidates for nutrition support. Because
clinical guidelines cannot be based solely on prospec-
tive randomized trials, the A.S.P.E.N. Task Force for
Revision of Safe Practices for Parenteral Nutrition con-
ducted the 2003 Survey of PN Practices,4 focusing on
policies and procedures relating to ordering, com-
pounding, and administering PN and quality oversight
of this process. The final document published as “Safe
Practices for Parenteral Nutrition” was based primar-
ily on the recommendations of experts in the field and
was evidence-based for as much as the literature pro-

259
260 SERES ET AL
vided evidence to support these recommendations. The
results from this survey were used as a basis for the
revised “Safe Practices for Parenteral Nutrition” to
enhance the quality and efficacy of nutrition support.
Following is a summary and analysis of the responses
to the survey.
METHODOLOGY
Development of the Survey Instrument
One of the survey objectives was to identify common
practices related to ordering and compounding, admin-
istration of PN, and quality oversight of this process. A
questionnaire based upon the existing A.S.P.E.N. “Safe
Practices for Parenteral Nutrition” was developed to
obtain an overview of the variance and consistency
with current practices from a variety of healthcare
settings. It was designed to include both hospital- and
non– hospital-based PN practices. The survey instru-
ment was not tested or validated before its distribu-
tion, but it was reviewed by a multidisciplinary panel
of nutrition support practitioners and revised before
becoming available for participant responses. The sur-
vey was administered electronically through the
A.S.P.E.N. website and announced to the membership
via society journals and A.S.P.E.N. list servers.
Announcements inviting participation were also sent
to selected professional groups, including the American
College of Clinical Pharmacy, the American Society of
Health-System Pharmacists, the National Home Infu-
sion Association, and others. Participation in the sur-
vey was completely voluntary.
The survey instrument consisted of 45 questions
with multiple-choice and free-text responses. It was
organized into 5 sections: demographics of the respon-
dent, writing PN orders, computer order entry of PN
orders, problems with PN orders, and adverse events
related to PN. Questions in the demographic section
focused on information such as professional back-
ground (ie, MD, RN, RD, RPh, other) and primary
practice setting (ie, hospital, homecare, etc). The order-
writing section was designed to identify the discipline
responsible for writing PN orders, whether or not stan-
dard PN order forms were used, and the manner in
which PN components were ordered (ie, dextrose in
percent final concentration vs g/day, electrolytes in
mEq/L vs per day, etc). The computer order entry sec-
tion was designed to quantitate the use of computer-
ized order entry systems and automated compounding
devices. The final 2 sections, problems and adverse
events related to PN, were developed to capture the
type and frequency of harm associated with the com-
pounding and administration of PN formulations.
Data Collection
The survey was announced on the A.S.P.E.N. web-
site, in the society journals (eg, Journal of Parenteral
and Enteral Nutrition, Nutrition in Clinical Practice),
and list servers (eg, ASPENet) between June 1 and 30,
2003. Messages were subsequently posted to inform
potential respondents of the deadline for final submis-
sion of survey responses. Participants were assured
Vol. 30, No. 3
TABLE I
Professional background of respondents
Discipline Percent Response
Dietitian 55
Nurse 5
Pharmacist 32
Physician 7
Other 1
that their responses would be confidential and that
only aggregate responses would be reported.
Data Analysis
Descriptive statistics were used to characterize the
frequencies of surveyed practices. Questions with free-
text responses were analyzed for content to determine
if the responses were significant to the study. Data
were analyzed with the SPSS 11.5 (SPSS, Inc, Chicago,
IL) statistical package. Frequency data were assessed
with ␹2. The a priori level of significance was set at
ⱕ0.05.
RESULTS
Demographics
The demographic characteristics of the respondents
(n ⫽ 651) are presented in Table I. The majority of
respondents were registered dietitians (55%), followed
by registered pharmacists (32%). Hospitals (teaching,
nonteaching, and government) were the most common
primary practice setting (90%). The remaining 10% of
respondents worked in the home infusion setting.
Twenty-six percent of respondents indicated the aver-
age daily census for their organization was 400⫹
patients, whereas 22% serviced only 100 –199 patients
per day. Only 15% of respondents were preparing ⬎20
adult PN formulations or ⬎5 pediatric PN formula-
tions per day. A once-daily nutrient infusion system
was preferred by the majority of organizations (76%).
Approximately 54% (337 of 620) of those responding
to the question indicated that their organization used a
performance improvement (PI) process for various
components of the PN system. Specific components
identified as part of the PI process are listed in Table
II. The appropriate use of PN and accuracy of PN
orders were the most frequently used markers for PI;
costs of PN compounding and PN wastage rates were
monitored by ⬍30% of respondents that used a PI
process. Indicators reported in free-text answers but
TABLE II
Components of performance improvement process (n ⫽ 330)
Component
Percent
Monitored
Appropriate use of PN 81
Accuracy of PN orders 56
Catheter and infectious complications 56
Metabolic complications 49
Quality control for PN compounding 46
PN costs 29
PN wastage rate 25
May–June 2006 PARENTERAL NUTRITION SAFE PRACTICES
TABLE III
Methods for ordering PN base components
Protein g/kg/d,* g/d, g/L of PN, volume of %
original concentration, % final
concentration, g/total volume of
PN
Dextrose Infusion rate: mg/kg/min* or g/kg/h,
g/L of PN, g/d, kcal/day, volume of
% original concentration, % final
concentration, nonprotein kcal*
Intravenous fat emulsion g/kg/d,* g/d, g/L of PN, volume of %
original concentration, % final
concentration, g/total volume of
PN, kcal/day, volume of %
concentration to be added to PN
or infused separate from PN (ie,
200 mL of 20% lipid), ml/d*, ml/L
of PN, g per total PN volume,
nonprotein kcal*
*Methods identified from free-text responses.
not included as choices in the survey instrument
included (1) appropriate dose of nutrient, (2) appropri-
ate monitoring of PN, (3) whether recommendations
were followed, and (4) efficacy of PN.
Writing Parenteral Nutrition Orders
The physician on the primary medical or surgical
team responsible for the patients’ care was identi-
fied most often as the party writing PN orders (78%).
The specialty area of the physicians varied and
included endocrinology, gastroenterology, pulmonary/
critical care, nephrology, pediatrics, and family medi-
cine. The level of training also varied, ranging from
residency to clinical nutrition fellowship. Respondents
indicated that dietitians and pharmacists were heavily
involved in the order-writing process, either as individ-
uals or as members of a nutrition support service.
Additional healthcare practitioners, such as advanced
practice nurses, as well as physician assistants, are
also involved in the order-writing process. Respon-
dents were asked to comment on the professional group
involved with oversight of the PN order process, such
as development of standard PN order forms, product
review for inclusion/exclusion on the formulary, and
documentation/reporting of PN-related adverse events.
Pharmacy services, in collaboration with the nutrition
support service or a medical staff committee, was most
often responsible for this aspect of the process.
Approximately 48% of organizations ordered the PN
base components in percentage of final concentration
after admixture (eg, 20% dextrose) and 33% as the
volume of percentage of original concentration (eg, 200
mL of 50% dextrose). Several respondents reported
using a combination of methods to order the individual
macronutrients, as listed in Table III. Of note, there
was no standardization between home infusion agen-
cies and hospitals.
No consistent method was identified for ordering of
electrolyte components or quantities. Use of the elec-
trolyte salts (eg, sodium chloride, potassium chloride)
was favored over the use of the individual electrolyte
cations or anions (eg, sodium, potassium, chloride, ace-
tate). However, the quantity of electrolyte ordered was
261
TABLE IV
Methods by which PN electrolyte quantities are ordered
Quantity Expression
Percent
Response
mEq/L or 100 mL for neonates 43
mEq/d 39
mEq/Total volume 38
mEq/kg 16
mmol/Total volume N/A*
Volume (mL) of multielectrolyte concentrate N/A*
formulation
Volume (mL) of original electrolyte N/A*
concentration (eg, 25 mL of 10% NaCl)
mg/d (For calcium gluconate) N/A*
mmol/L N/A*
*These methods were not included as a selection in the survey but
were provided by respondents when asked whether other methods
were used.
expressed in a variety of ways. The number of mEq/L
(or per 100 mL for neonates), mEq per day, and mEq
per total volume were the 3 most common methods.
Table IV includes a list of all the methods used. Phos-
phorus was ordered in mmol of the salt (eg, potassium
phosphate or sodium phosphate) by 57% of respon-
dents and in mEq of the cation by 26% of respondents.
Approximately 17% used both methods of nomencla-
ture. Some amino acid products are manufactured with
electrolytes as buffers (ie, chloride, acetate) or contain
electrolytes as components (ie, sodium, phosphorus).
When queried as to whether these electrolytes were
considered in the total electrolyte delivery, 71% did not
include these in the total amount during the writing of
PN orders. The pharmacy was allowed to adjust certain
electrolyte additives such as acetate or chloride in 62%
of respondent’s organizations.
The overwhelming majority of organizations (90%)
routinely ordered a standard volume of a commercially
available multiple trace element product vs each trace
element ordered separately. Approximately 1 of 5
respondents (22%) adjusted the dose of trace elements
according to patient clinical condition (ie, gastrointes-
tinal losses, liver failure).
A total of 88% of respondents reported using a stan-
dardized PN order form. Improved interpretation of
PN orders and reduced errors were perceived by 83% to
be a result of using standardized PN order forms. Edu-
cational information was frequently included either on
or with PN order forms, as those writing PN orders
were felt to lack knowledge of PN preparation. Respon-
dents from the home infusion setting reported that the
primary reason for not using a standardized PN order
form (32%) was the inability to standardize the order-
ing process because orders were received from multiple
organizations. Only 54% of respondents reported using
standard order forms for laboratory and patient care
orders related to PN.
There was a significant difference found between the
use of standard PN order forms and how often PN
orders required clarification. PN orders written with
the use of standard order forms seldom required clar-
ification, whereas PN orders required frequent clarifi-
cation if standard order forms were not used (p ⫽ .015).
There was a trend (p ⫽ .085) between the use of stan-
262 SERES ET AL Vol. 30, No. 3

dard order forms and the reasons that PN orders

required clarification (eg, incorrect or unstable macro-
nutrient, inappropriate dosage according to disease
state).
Duration of administration of IV fat emulsion (hang
time), whether administered separately from PN or as
a component of a total nutrient admixture (TNA), was
not consistent. Most respondents allowed fat emulsion
to hang for a minimum of 12 hours and a maximum of
24 hours when infused separately from PN. The
patient population appeared to influence the practice
for maximum hanging time, with a 12-hour maximum
hang time for adults but extending to a 24-hour hang FIGURE 1. Parenteral nutrition orders written or received by organi-
zation.
time for pediatric/neonatal patients. Responses for
minimum and maximum hang time of fat emulsion as
part of a TNA were variable.
adverse events, and 10% reported that no adverse
Computerized Prescriber Order Entry (CPOE) and events occurred. Of those organizations reporting any
Outsourcing adverse event, 35% required increased patient moni-
toring, 25% reported that the adverse event resulted in
Only 31% of those who responded to the question temporary or permanent harm, 3.3% (n ⫽ 16) reported
(169 of 545 respondents) about computerized order the adverse event was considered a near-death event,
entry of PN (CPOE) currently prescribe PN using this and 1.5% (n ⫽ 7) reported death as a direct result of an
type of order entry process. Of these, 88% use CPOE for adverse event of PN. The components of PN most often
adult, 58% for pediatric, and 55% for neonatal patients. associated with these errors included electrolytes
Although 88% of those who responded to the question (71%), insulin (31%), and dextrose (31%). Other errors
regarding CPOE (144 of 164 respondents) indicated included wrong infusion rates, wrong PN volumes,
that their organization used an automated compound- incompatibility of calcium and phosphorus, computer
ing device for PN, this sample represented only about order entry, and administrations to the wrong patient.
22% (144 of 651 respondents) of the total responses to Fifty-five percent of respondents identified these errors
the survey. Pharmacists were required to enter orders as relating to the ordering process 1%–25% of the time,
into the automated compounding device 84% of the whereas 17% responded that 76%–100% of the time
time because this device did not interface with the these errors occurred during the PN ordering process.
CPOE system. The final question asked institution-based respon-
The majority (85%) of organizations compounded PN dents about their policies for allowing a patient to
formulations in their own facility and did not outsource bring in or continue a PN formulation compounded at
this responsibility. When organizations did outsource an outside facility. Approximately 43% of respondents
PN compounding, 95% responded that a pharmacist reported that this practice was allowed. The most com-
reviewed the order before delivery to the compounding mon reasons for barring this practice were safety and
facility. liability issues. A summary of responses is shown in
Table VI.
Problems With PN Orders
DISCUSSION
The section of the survey evaluating problems with
PN orders was designed to collect data related to com- The purpose of this survey was to identify current
pounding and administration errors. Over half of the policies, procedures, and quality oversight being used
organizations (55%) process 0 –10 PN orders per day, by healthcare organizations for ordering and com-
whereas 15% processed ⬎30 PN orders per day (Figure
1). Approximately 61% of respondents noted that
PN orders required clarification up to 10% of the time. TABLE V
The 3 most common reasons for order clarification were Reasons for PN order clarification
illegible writing, missing essential nutrient, and incor- Often Seldom Rarely
Reason
rect or unstable macronutrient content. Other reasons (%) (%) (%)
for order clarification and their frequency are shown Illegible order 25 25 50
in Table V. Although the majority of organizations Essential nutrient missing 20 27 53
responding (60%) observed only 1–5 errors per month Incorrect or unstable macronutrient 18 35 47
content
related to PN, approximately 5% reported ⬎11 errors Incompatible additives 17 31 52
per month. Nutrient doses outside normal 17 31 51
range
Adverse Events Related to PN Formulations Inappropriate dosage based on 15 29 56
disease state
Forty-six percent of respondents reported incidents Infusion at rate not prescribed 14 30 55
Incorrect PN volume 14 26 60
of harm directly attributed to PN during the past 2 Pharmacy compounding error 1 13 86
years, 44% of respondents were not aware of any
May–June 2006 PARENTERAL NUTRITION SAFE PRACTICES
TABLE VI
Reasons for not allowing infusion of PN compounded by an outside facility
Issue
Responses
(n)
Safety/legal liability
Verification of PN contents
Against policy
Assure formula appropriate for current
patient condition
PN sterility
Storage conditions
PN stability
Billing/reimbursement
Compatibility with infusion pumps/sets
pounding PN. In addition, this information would
serve as a foundation for revising previously published
safe practice guidelines for PN. It was interesting to
note that the majority of respondents’ institutions pre-
pare ⬍20 PN orders daily. No previously published
data have been analyzed to determine the correlation
between overall institution size and the number of PNs
written. As research increasingly supports the use of
enteral nutrition over PN for patients with a functional
gastrointestinal tract, one might expect a lack of cor-
relation between the size of an institution and the use
of PN if, for instance, larger academic institutions
change behavior more quickly in response to published
clinical research findings.
Providers in the home infusion setting made up only
10% of the respondents. The low response rate from
this group of practitioners serves to underscore the
difficulty in reaching such a widely dispersed group
and the need to increase recruitment of home infusion
providers into societies such as A.S.P.E.N. The low rate
of response from this group makes comparisons with
practices in hospitals and home infusion difficult.
PI programs were used by over half of respondents,
but less than one-third included quality control of
PN compounding as a component of this process.
Errors occurring in the compounding process of
sterile preparations have come under scrutiny due to
adverse events associated with microbial contamina-
tion. Over the past 20 years, there have been reports
of patient morbidity from improperly prepared PN
formulations.5–7 Common factors in these cases in-
volved lack of policy and procedures and lack of process
validation for sterile compounding. According to a
national survey of quality-assurance activities for
pharmacy-compounded sterile preparations conducted
in 2002, only 39% of respondents (n ⫽ 182) reported
having such a program.8 The need for consistent eval-
uation of aseptic technique and in-process or end-prod-
uct testing of compounded PN formulations has been
recognized by the pharmacy profession with the publi-
cation of the United States Pharmacopeia (USP) Chap-
ter 797. This chapter of the USP and the National
Formulary outlines the practice standards for com-
pounding sterile preparations and is enforceable by
regulatory agencies.9 Thus, pharmacies compounding
PN may be inspected for compliance with these stan-
dards by state boards of pharmacy, the US Food and
Drug Administration (FDA), and accreditation organi-
263
zations such as the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO). Failure of phar-
macies to develop and implement these practice stan-
dards may result in the FDA ultimately restricting the
43 compounding of sterile products to a select group of
39 specially trained and certified professionals.
27
22
The responses to questions regarding responsibility
for PN order writing yielded several notable findings.
21 Of particular interest was that nutrition support ser-
20 vices were involved in PN order writing 31% of the
19
10
time, despite the general perception that nutrition sup-
4 port services are a thing of the past. Of further interest
is the significant role that physician assistants and
advance practice nurse practitioners play in the order-
writing process. Although there are certifying exami-
nations and organizations devoted to nurses in nutri-
tion support, there are none for physician assistants. It
was not surprising that physicians were most often
identified as being responsible for writing PN orders. It
was clear, however, that the training level of the phy-
sicians varied greatly, and it seemed that resident
physicians were most often the ones responsible. Phar-
macy and, to a lesser extent, dietitians were also
involved in order writing, approximately 40% of the
time each. The oversight of the order-writing process
was most often the responsibility of the pharmacy
(71%), a nutrition support service or committee (51%),
or a medical staff committee (51%). It is likely that
there was significant overlap of responses to the latter
2 options, given that both contained a committee.
Several problems with the ordering process for PN
were identified. It is of particular concern to the task
force that so much variability exists in the manner in
which PN components are ordered. This is seen as a
potential source of error when orders are communi-
cated from inpatient to outpatient settings, and vice
versa, and may be the largest area of change in practice
resulting from the revised Safe Practices Guidelines.2
There is a significant lack of concordance between the
ordering methodology for base components, electro-
lytes, and other additive components and the recom-
mendations contained in the revised Safe Practices
Guidelines. The task force recommended that all PN
components be ordered in amounts per day to avoid
any misinterpretation. This means that the most com-
monly reported methods for ordering base components
(ie, dextrose, fat, amino acids), such as percentage of
final concentration (eg, 25% dextrose) and volume of
percentage of original concentration (eg, 250 mL of 70%
dextrose) should no longer be used. Although it may be
understood among physicians who are writing PN
orders that percentage of final concentration of dex-
trose is just another way to describe g of dextrose per
day, this can often be misinterpreted by the pharma-
cists, dietitians, or nurses involved in the PN process.
This disparity was just as prominent in the ordering of
electrolytes. Although most respondents reported
ordering in the electrolyte salt (eg, NaCl or Na acetate),
only 39% of respondents indicated ordering in mEq (or
mmol) per day.
There was a great deal of variability in policy for
infusion of fat emulsion. When fat emulsion is admin-
istered as a separate infusion from the dextrose and
264 SERES ET AL
amino acids, minimum hanging time allowed most
often varied from 4 to 12 hours, with 12 hours being
most frequent. There were 16% of respondents lacking
any minimum hanging time policy in this group, and
approximately 6% of respondents indicated a mini-
mum hanging time of 24 hours. Some respondents
indicated that fat emulsion infusion rates were limited
by a maximum rate instead of a minimum infusion
time. Maximum hanging time for separately infused
fat emulsion was most often reported as either 12 or 24
hours. When fat emulsion was included in a TNA,
minimum hanging times were reflective of minimum
allowable cycle times and were most often 8, 12, or 24
hours. Maximum allowed infusion time reported was
24 hours in nearly all respondents, suggesting a near-
universal acceptance of 24 hours as a maximal in-
fusion time for TNA. This was probably the only prac-
tice that achieved this level of concordance in the entire
survey.
Most respondents indicated that a standard order
form was used when PN was ordered. Home infusion
respondents most frequently indicated a lack of stan-
dardization, citing different referral sources as the rea-
son standard PN order forms were not used. These
data should be assessed with caution as respondents
indicated a degree of confusion between the use of
standardized PN order forms and the use of standard
predesigned PN formulations. The significant differ-
ence between the use of standard PN order forms and
how often PN orders required clarification was one of
the many reasons that our task force advocated the use
of standard PN order forms in the revised Safe Practice
guidelines.
One of the most common reasons necessitating a
pharmacist contacting the prescriber was illegible
writing. Approximately 25% of respondents answering
this question (n ⫽ 496) identified that PN orders
needed to be clarified “very often” or “often” as a result
of illegible writing. This is dramatically higher than
the rate recently published by USP using their MED-
MARX system as the data collection source for medi-
cation errors.10 This system is an Internet-accessible
program that has been used by ⬎775 subscribing hos-
pitals and health systems to report medication errors.
Between the years 1999 and 2003, analysis of MED-
MARX data found that 3% of all medication errors
reported were associated with unclear or illegible
handwriting. The higher frequency of illegible orders
captured by our survey may be due to the complex
nature of PN orders. Orders for PN are often messy
and hard to read due to corrections of math errors or
improper selection of components.
CPOE may serve as one strategy to reduce errors
and improve PN safety. One study reported a substan-
tial reduction in the frequency of PN orders requiring
clarification once CPOE was instituted in a neonatal
intensive care unit, a pediatric intensive care unit, and
a general pediatrics unit.11 Similar to our survey, 25%
of PN orders written on the paper-based form required
clarification. Only 1.6% of the orders generated with
CPOE needed clarification.
The most concerning statistics revealed by the sur-
vey were the frequency of errors and the severity of
Vol. 30, No. 3
TABLE VII
Error categories and associated harm*
Category Definition
A Circumstances or events that have the capacity to
cause an error (no error)
B An error occurs but does not reach patient or
cause harm (error, no harm)
C An error occurs and reaches patient but does not
cause harm (error, no harm)
D An error occurs, it reaches the patient, and it
requires increased patient monitoring (error, no
harm)
E An error occurs; it results in temporary harm,
and treatment or intervention needed (error, harm)
F An error occurs and it results in harm that
requires initial admission or prolonged
hospitalization (error, harm)
G An error occurs that results in permanent patient harm
(error, harm)
H An error occurs that results in a patient death (error,
harm)
I Cannot assess harm at the time error occurs (error,
death)
*Adapted from the National Coordinating Council for Medication
Error Reporting and Prevention.
harm attributed to these errors. Almost two-thirds of
respondents reported observing between 1 and 5 errors
per month related to PN. Furthermore, about two-
thirds of respondents estimated that their organiza-
tions prepared 0 –10 PN formulations per day. If this
were truly representative data, extrapolating this
information out to 1 month, one could propose an error
rate ranging from 0.3% to 1.6% (assuming a range of
1–5 errors per 10 PNs per day for 30 days). To our
knowledge, there are no published data on error rates
associated with PN considered as “one” medication. As
a comparison, MEDMARX reported a medication error
rate of 3.6% for insulin and 2.1% for potassium chlo-
ride, both of which are high-alert medications, as well
as additives that can be found in PN formulations.
Interestingly, electrolytes, such as potassium chloride,
were identified in our survey as the PN component
most often associated with errors. Insulin and dextrose
were the second most common ingredients of PN for-
mulations linked to errors. Because there are up to 8
separate electrolyte salts that can be added to PN
formulations, it follows that most errors are associated
with these components. However, it is difficult to
understand why more errors occur with insulin vs
amino acids, vitamins, trace elements, or histamine2-
receptor antagonists. Unfortunately, errors with insu-
lin and potassium chloride are associated with the
most harm (error categories E–I, Table VII).
Interestingly, there was a difference in adverse event
reporting, including severity, according to the disci-
pline. Adverse events requiring an increase in patient
monitoring were reported most frequently by nurses,
followed by physicians, pharmacists, and dietitians
(p ⫽ .001). This observation appears intuitive at first
because nurses are at the patient’s bedside during PN
administration. However, this finding may be related
to a small number of nurse respondents (n ⫽ 25) com-
pared with pharmacists (n ⫽ 186) and dietitians (n ⫽
232). Dietitians were found to be unaware, more so
May–June 2006 PARENTERAL NUTRITION SAFE PRACTICES
than other disciplines, of any adverse event occurring
as a result of PN administration. A new section was
added to the revised Safe Practice guidelines empha-
sizing the need for monitoring the patient’s response to
PN therapy to ensure safe administration.
The task force was also interested in identifying how
often institutions allowed the administration of PN
formulations compounded at outside facilities once a
patient was admitted to an inpatient setting. Patients
often request that their PN formulations compounded
for home administration be infused in the hospital
because a charge has already been incurred. The
majority (57%) of institutions did not allow this prac-
tice.
Despite significant limitations, the results of this
survey point to a number of relevant issues related to
delivery and quality assurance practices in the provi-
sion of PN. Because the number of practitioners
involved in the provision of PN nationally is unknown,
it cannot be assessed whether the respondents of the
survey represent an adequate sample of the provider
population. The proportion of respondents appeared
not to be representative of the A.S.P.E.N. membership
(eg, physician respondents 7% vs A.S.P.E.N. physician
membership of 18% in 2003). Further, physicians and
nurses composed very small fractions of the total
response, possibly invalidating any statistical compar-
ison of responses by discipline. The methodology used
in developing this survey instrument may also limit
the interpretation and applicability of the findings. The
results reported here are derived from a survey that
was designed to obtain a subjective overview of policies
and procedures related to ordering and compounding
PN, as well as the quality oversight of this process. The
population surveyed was limited due to budgetary and
time constraints and included persons who were on
A.S.P.E.N. e-mailing lists or read A.S.P.E.N. journals
in which the survey was advertised or who heard about
the survey by word of mouth. Further, it is not known
whether any given institution was represented by more
than 1 respondent.
265
Despite these limitations, the task force found the
results useful in identifying practices pertinent to the
revision of the Safe Practices guidelines. The task force
believes that implementation of these guidelines by
organizations will ultimately result in the safer provi-
sion of PN.
ACKNOWLEDGMENTS
The authors thank A.S.P.E.N. for their support in
the collection and management of survey data.
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