Commentary: Preventing Errors Related to Total Parenteral Nutrition

April 10, 2013 | Strategic Insights for Health System


Despite being a complex and high-alert medication, only 58% of healthcare organizations have safeguards in place to prevent patient harm from errors related to the process of administering parenteral nutrition, states the author of a commentary from the April 2013 edition of the Agency for Healthcare Research and Quality’s (AHRQ) online case study review, WebM&M. In the spotlight case, a three-year-old boy on chronic total parenteral nutrition due to multiple intestinal resections was admitted to an academic medical center for anemia. Two days later, the patient's serum sodium was noted to be low at 130 mEq/L, below the normal range of 135 to 145 mEq/L, and the team ordered to increase the amount of sodium in the admixture from 5.2 mEq/kg/day to 5.5 mEq/kg/day based on a standard formula. The boy developed worsening abdominal pain overnight, as well as a headache that wasn’t present on admission. During rounds, the resident caring for the patient examined the bag to see how much sodium the boy was receiving and discovered that the bag had a sodium concentration of 55 mEq/kg/day—10 times greater than the intended sodium concentration of 5.5 mEq/kg/day.

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