Parenteral Nutrition Compounding Research Articles

Detection and reduction of errors in parenteral nutrition compounding through gravimetric and product control

ObjectiveTo analyze the errors in the preparation of parenteral nutrition in a Pharmacy Service, detected through an already consolidated gravimetric and product quality control, and compare them with those detected during the initial years of implementing this quality control. MethodsAll errors detected through quality control in the compounding of pediatric and adult parenteral nutritions between 2019 and 2021 were prospectively analyzed. This quality control consisted of 3 sequential processes: a visual check, a gravimetric control, and a product control. Errors were classified as gravimetric, when the nutrition had a deviation of more than 5% from the theoretical weight, or as product errors when a qualitative or quantitative error was detected upon reviewing the remainder of the components used. These errors were analyzed in terms of type and the component involved. A comparison was made with the errors detected during the implementation phase of this quality control from 2016 to 2018. ResultsA total of 41,809 parenteral nutritions were reviewed, and 345 errors were detected (0.83% of the preparations); of these, 59 errors were found in pediatric nutritions (0.68% of them), and 286 in adult nutritions (0.86% of them). Among these errors, 193 were of gravimetric nature, while 152 were detected through product control. The main components involved in product errors were electrolytes, primarily due to the addition of excessive volumes and the use of incorrect components. A significant absolute reduction of 0.71% (P < .05) in the total number of errors was observed when compared to the implementation phase. This reduction was consistent in both gravimetric errors (−0.59%) and product-related errors (−0.12%) (P < .05). ConclusionsComprehensive quality control of parenteral nutrition preparation is an easily implementable tool that effectively detected and prevented significant errors. Furthermore, its widespread adoption contributed to a reduction in the overall error count.

Safety in parenteral nutrition compounding.

Parenteral nutrition (PN) compounding is a complex process that requires knowledge and training to ensure the safety and efficacy of this form of nutrition support therapy. Unfortunately, errors and lack of adherence to safe PN compounding recommendations and sterile compounding requirements have resulted in patient injury and death. These lapses in the safe provision of PN have been the result of various factors, including a lack of understanding of PN compatibility, stability, and sterility requirements, as well as drug product shortages and order entry errors. This review will describe the current challenges with the education and training regarding PN compounding, compatibility and stability of PN admixtures, simultaneous administration of nonnutrient medications with PN admixtures, and specific challenges with special populations such as neonates, pediatrics, and those receiving home care.

Centralized insourcing of sterile compounding: One multihospital health system's journey.

The process and challenges associated with an initiative to pivot from insourcing the batch compounding of high-volume sterile preparations to insourcing patient-specific compounding of parenteral nutrition (PN) at a health-system central fill pharmacy (CFP) serving 8 hospitals in central Florida are described. The insourcing initiative was prompted by a need for greater oversight of sterile compounding to ensure patient safety and the potential for cost savings. In 2014 the health system opened a CFP to provide replenishment of automated dispensing machines and insourcing of 19 compounded sterile preparations (CSPs) as the hub of a hub-and-spoke distribution system for 8 local hospitals. The need to comply with a 2016 proposed Food and Drug Administration requirement limiting the distribution by 503A pharmacies of non-patient-specific CSPs beyond 1 mile and the state of Florida's scope of practice definition related to sterile compounding prompted the CFP to switch from CSP insourcing to PN insourcing. The business case was based on substantial projected cost savings of more than $900,000 annually from PN insourcing versus outsourcing. A hybrid model for insourcing PN preparation was developed by using the PN compounding device, solutions, and additives from different vendors. Standardization of PN formulations and order templates streamlined the ordering process and reduced the unnecessary use of additives and associated costs. With careful planning, the CFP successfully pivoted from insourcing CSPs to insourcing PN. A collaborative approach with early and frequent communication among key health-system and vendor stakeholders was vital to the success of the initiative.

Strengths, weaknesses, opportunities, threats analysis on choice of multi chamber bag or compounded parenteral nutrition

Reasons for choosing parenteral nutrition (PN) products depend on healthcare institutions internal and external factors. A decision to start, continue, scale-up, scale down, or stop compounding of PN involves multiple stakeholders. This study is an effort to analyze such factors and recommendations on decision-making. A strength, weakness, opportunities, threats (SWOT) analysis was prepared in consultation with major PN providers in the UAE and comparing to international best practices. Based on the SWOT analysis, a set of recommendations was prepared using the GRADE system (classification of quality of evidence and strength of recommendation). Feedback on the SWOT analysis and recommendations were collected from the PN providers. The SWOT analysis and recommendations address aspects of the choice of MCB-PN or compounded PN. It includes considerations on PN indication, availability of ingredients, types of patients, safety, and cost management with labor, automation, and outsourcing. It was received well. The SWOT analysis and recommendations are useful in decision-making in complex therapy like PN. It helps in institutional decisions on choices of MCB-PN or compounded PN. The impact of the recommendations is to be measured in the future.

Technology in Parenteral Nutrition Compounding.

Technology is constantly being used in novel ways, and its use in the practice of medicine is no exception. Examples of this include computer physician order entry, barcode-medication scanning, electronic health records (EHRs), and bedside patient charts, to name a few. Compounding parenteral nutrition has been included in this technological revolution, with improvements such as barcode-assisted medication preparation systems and EHR-to-compounder interfaces. Along with some of these electronic advancements come the inevitable improvements and challenges, which are explored in this article.

PP089 Health Technology Assessment Of An Automated Compounding Of Parenteral Nutrition

INTRODUCTION:Pediatric parenteral nutrition is mainly used in neonatal intensive care units (NICU) and requires close collaboration with the hospital pharmacy, especially for manufacturing time, application, preparation and delivery (1). In this context, a Health Technology Assessment (HTA) to evaluate an automatic system compared with a manual system was carried out.METHODS:The Decision-oriented HTA (DoHTA) method (2), coordinated by Bambino Gesù Children's Hospital (BGCH) HTA Unit, was applied to carefully assess the technology. It was developed starting from the European Network for HTA (EUnetHTA) Core Model® and integrated with the Analytic Hierarchy Process (AHP). Its purpose is to identify all the relevant assessment aspects of automatic system integrating the evidence from the scientific literature with experts’ judgments and the specific context analysis for BGCH: an evaluation scheme inherent safety, clinical effectiveness, technical and organizational aspects (represented by a decision tree at three levels: dimensions of evaluation, I and II level indicators) was subsequently created. A weight was finally associated to each identified element and the alternatives’ ranking was defined.RESULTS:The study results show a “performance value” associated with the automatic system greater than about thirty-two percentage points compared to the manual system.CONCLUSIONS:At the current state of the scientific evidence and the results of analysis carried out by the working group, it is believed that the choice should be made to introduce the automatic system is available in BGCH.More specifically, from the point of view of safety, automatic system is safer for both patient and operators; about clinical effectiveness, the system improves the nutritional intake, allows a reduction of post-infusional adverse events and the use of antibiotic therapy; concerning economic aspects, the analysis of available data shows a substantial equivalence between the alternatives considered; the technical-functional aspects show an improvement according to almost all indicators; organizational aspects show a slight improvement in the working and in process management and finally the legal aspects indicate a slight advantage for the automatic system.

Shielding Parenteral Nutrition Solutions From Light: A Randomized Controlled Trial.

Oxidant stress is implicated in the pathogenesis of bronchopulmonary dysplasia (BPD). Light induces peroxide generation in parenteral nutrition (PN) solutions, creating an oxidant stress. Shielding PN from light decreases its peroxide content, which has nutrition and biochemical benefits in animals and humans. This study aims at determining whether full light protection of PN decreases the rate of bronchopulmonary dysplasia and/or death in very low-birth-weight infants. Multicenter randomized controlled trial of photoprotection, using amber bags and tubing initiated during compounding of PN and maintained throughout infusion in the light-protected (LP) group. The control group (light exposed [LE]) received PN exposed to ambient light. Depending on centers, lipids were infused either separately or as all-in-one PN. In total, 590 infants born <30 weeks gestational age were included. At randomization, LE and LP groups did not differ clinically except for maximal FiO2 before 12 hours. The rate of BPD/death was not different between groups at 28 days (77% LP vs 72% LE, P = .16) or at 36 weeks corrected age (30% LP vs 27% LE, P = .55). Multivariate analysis showed no significant effect of photoprotection on BPD and/or death. The rate of BPD/death was significantly lower (odds ratio, 0.54; 95% confidence interval, 0.32-0.93; P = .02) in infants receiving all-in-one PN vs those who received lipids separately. This study did not show significant beneficial effects of photoprotection. Since the decreased rate of BPD/death found with all-in-one PN relates to a center-dependent variable, this warrants further investigation.

Validation of aseptic technique of parenteral nutrition compounding in a pharmacy service according to USP Chapter 797

During the process of parenteral nutrition preparation, aseptic techniques by nursing staff must be guaranteed. Chapter 797 of the United States Pharmacopeia classifies the risk levels of sterile compounding and defines the requirements that must be followed throughout the compounding. To describe the development of an aseptic technique validation procedure for nurses who compound parenteral nutrition at the compounding area Pharmacy Service according to Chapter 797 United States Pharmacopeia guidelines. Chapter 797 United States Pharmacopeia was reviewed and parenteral nutritions were classified as medium risk level compounded sterile preparations. We adapted the United States Pharmacopeia guidelines for medium risk level compounded sterile preparations and we performed a procedure of aseptic technique validation for parenteral nutrition compounding. The aseptic technique validation procedure allows the validation of aseptic management quality of nursing staff. The procedure has been incorporated into practice and is performed monthly by the nursing staff in the nutrition area.

Automated Compounding of Parenteral Nutrition for Pediatric Patients: Characterization of Workload and Costs

Parenteral nutrition (PN) compounding in large hospital centers is now largely automated using volumetric pump systems. No study has examined the pharmacy workload and costs associated with this process. This study was designed to characterize these elements at our center and to identify areas for potential improvement. We retrospectively analyzed all PN orders compounded from May 19, 2007, to June 25, 2010. Patients were divided into groups according to the ward where PN was initiated. The age and weight of patients at initiation of PN were similar throughout the study, except in neonatology, where initiation now occurs earlier in life (age 1.3 ± 2.7 days in 2010 vs. 3.4 ± 9.4 in 2007; p=0.003). An average of 894 orders per month were compounded. A total of 59% of orders were for neonatal patients. The average cost of source solutions per PN order increased from Can$23.27 in 2007 to Can$37.78 in 2010. Partially used source solutions discarded at the end of the day represented between 7.7% and 9.2% of total source solution cost. Amino acids in 3-L bags were responsible for the largest waste, with Can$953 to Can$1048 wasted monthly. PN compounding at our center represents an important workload and increasing costs. A reduction in source solution waste, for example, by reducing the use of large source solution containers, would be beneficial.

Safe Practices for Compounding of Parenteral Nutrition

Safe practices for sterile compounding are essential to preventing errors, particularly with parenteral nutrition (PN). This article reports several areas of errors in PN processes and provides recommendations for error prevention.

Issues Surrounding Compounding of Parenteral Nutrition

Issues Surrounding Compounding of Parenteral Nutrition

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

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Practical aspects of multichamber bags for total parenteral nutrition

Ready-to-use all-in-one admixtures are standards for short and long-term parenteral nutrition. Their limited stability does not allow storage over prolonged periods of time. Multichamber bags represent industrially manufactured near complete standard parenteral nutrition premixes with extended shelf lives. This review focuses on the characterization of multichamber bags, their influence on parenteral nutrition practice, the need for individual parenteral nutrition compounding, and the role of the pharmacist in the nutrition team. The all-in-one admixture concept, its correlation with parenteral nutrition effectiveness, safety, and pharmaceutical issues are reviewed. Multichamber bags, the bag material, their use and practical handling are addressed. Newly developed container materials are mainly responsible for the increased stability of multichamber bag parenteral nutrition premixes. Multichamber bags are used for (standard) parenteral nutrition in adults. Multichamber bags cannot eliminate individualized all-in-one parenteral nutrition compounding. Pharmaceutical assistance with expertise in compatibility and stability is mandatory for the nutrition team to implement and control good parenteral nutrition practices, e.g. to convert multichamber bags into complete ready-to-use all-in-one admixtures or to compound individualized regimens. The incorporation of additional components into parenteral nutrition admixtures (pharmaconutrients, drugs) must rely on documented compatibility with the parenteral nutrition admixtures. Multichamber bags have their advantages and limitations. Studies on the effectiveness and costs of multichamber bags are needed to meet the expectations of pharmacists, physicians, nurses, and industry for optimal parenteral nutrition in patients.

Reflections on current issues concerning the stability of parenteral nutrition mixtures

Reflections on current issues concerning the stability of parenteral nutrition mixtures

The cost benefits of R.D./PHARM. D. service

The R.D./Pharm. D. service was implemented to assist the physician in providing optimal parenteral nutrition support by conducting nutritional assessments, identifying early complications, monitoring, and evaluation of the patient. This team included a clinical dietitian who provided the nutritional assessment of the patient. The pharmacist related the nutritional needs to the formulation and the compounding of parenteral nutrition, optimizing of other IV's or medication as these pertained to total fluid volume, route of administration, or nutritional significance.