Parenteral Nutrition Process Management for Infants – TCRM


Parenteral vitamin is an important a part of the preliminary dietary help offered for vital preterm or time period neonates. Worldwide, alternative ways of compounding parenteral vitamin (PN) for neonates are utilized.1,2 High-risk PN preparation steps are normally managed by the hospital’s pharmacy in collaboration with the neonatal service. In some instances, the entire course of, together with the compounding of PN, is organized by the neonatal service. Both methods embody dangers and constraints.

In our hospital, PN is both ready on the central pharmacy by skilled pharmacy technicians or on the neonatal ward by nurses with none involvement of the pharmacy employees. The place the place PN is ready is determined by the doctor’s analysis in regards to the emergency to start out or adapt vitamin, which can be pressing in vital conditions like very preterm infants, (very) low start weight, metabolic dysfunction, or vital sickness.

In 2015, the Inspection générale des affaires sociales (IGAS) of France printed the report of a nationwide survey on PN therapy.3 This survey was carried out following the dying of 5 infants within the hospital of Chambery, France in 2012 attributable to the administration of contaminated PN. The IGAS got here to the choice to completely prohibit on-ward preparations for PN therapy and to delegate the entire accountability to pharmacists. Due to this report and the totally different PN preparation practices at our hospital, our curiosity was directed on the scenario of security of PN therapy at our website.

As PN preparation is understood to be probably the most vital steps inside its administration4 and a serious threat issue for healthcare-associated infections in neonates,2 its centralization on the pharmacy is really helpful.5 The deliberate centralization at our website will embody the take-over of PN compounding nonetheless carried out on-ward through the week (Monday to Friday) in a primary step and through weekends by the pharmacy emergency service in a second step.

ISO9001 licensed, the hospital pharmacy has a high quality administration system to guarantee pharmaceutical companies. Conforming to the rules Q96 of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) in addition to GMP7 of the European Commission’s EudraLex on high quality threat administration, a threat evaluation of this hybrid mannequin was carried out.

This research goals to check the administration processes of the 2 PN making ready websites (NICU and pharmacy) by way of a preliminary threat evaluation (PRA) and describes our middle’s analysis of the dangers and advantages related to transitioning in direction of common pharmacy PN preparation for our NICU.

Methods and Materials

Process Description

At our college hospital, PN containing glucose and amino acids with or with out electrolytes was ready on the hospital pharmacy in addition to on the ward of the NICU.

During opening hours, for medically secure sufferers, PN is mostly ready at our hospital pharmacy. The course of being time consuming, which means that the prescription order should be positioned at midday on the newest for a supply of the person PN at 5:00 pm, nurses have to arrange PN on the ward for emergency conditions or unstable sufferers. Furthermore, because the pharmacy doesn’t put together PN through the night time, weekend or vacation, NICU nurses have additionally to arrange them for brand spanking new admissions throughout these shifts.

The neonatal ward additionally wished for sustaining the pliability and data of making ready PN on-ward when a preparation on the pharmacy is just too time-critical.

At our hospital, no information is out there for infections associated to contaminated PN or electrolyte disturbances associated to under- or over-concentrated PN. This lack of knowledge is as a result of uncommon strategy of analyzing PN therapy as root trigger for these instances. What is understood, is that 34% of PN ready on the ward is more likely to not conform to the medical prescription in a spread from 90% to 110%.8


At the second of this research, every prescription was written manually on a PN order kind which was edited and validated by neonatologists and pharmacists. This kind – solely used for PN preparation on the pharmacy – was faxed to the pharmacy the place technicians transcribed the PN order in a validated Excel sheet interfaced with the compounding automate BAXA EM 2400.9 Before the PN preparation, every prescription was double-checked and validated by a pharmacist.

The pharmacy, certified by the nationwide authority Swissmedic, adopted Ph. Helv. GMP pointers and was subsequently working with a GMP class A Horizontal Laminar Airflow Hood (HLAH), positioned in a GMP class B cleanroom, working with skilled and certified personnel.10 The high-risk PN preparation was accomplished by way of an automate (BAXA EM 2400) and analytical controls for quantitative dedication of vital parts (glucose, Na+, Ok+, Ca2+, Mg2+) had been carried out on every ultimate product earlier than pharmaceutical launch of the PN preparation.11,12

Neonatal Intensive Care Unit

When PN was ready by nurses on the ward, one other order kind was used than the validated one for the pharmacy. This kind served as instruction for the preparation in addition to for transcription of substances on the label to be affixed on the ready PN syringe or bag. New nurses had been skilled by reference nurses for PN therapy on the dealing with, preparation and administration of PN. No common requalification was necessary.

PN was ready manually by nurses following the handwritten medical prescription in a non-classified and non-qualified HLAH positioned contained in the NICU pharmacy. The transcribed labels in addition to the quantity withdrawn and uncooked resolution of vital parts like potassium (as hydrochloride or phosphate salt) had been double-checked by a second nurse or doctor. For all non-critical substances, the preparation of PN was carried out and auto managed by a single nurse solely. No analytical controls had been carried out for these on-ward preparations earlier than administration to the weak sufferers.

Even with an enormous employees of nurses, PN preparation represented a time-consuming job and lowered the time for sufferers’ care.

Preliminary Risk Analysis

Since a number of years, threat analyses are carried out within the subject of pharmaceutical science for high quality administration functions primarily based on the strategies utilized initially within the aeronautic and navy domains.13 Different sorts of threat evaluation strategies exist, of which the failure modes and results evaluation (FMEA), the failure modes, results, and criticality evaluation (FMECA), and the preliminary threat evaluation (PRA) are probably the most recognized and utilized.14 The FMEA and FMECA are imagined to assess dangers in a present, well-established setting and to outline if an motion plan to safe this setting should be carried out.15 The PRA is carried out the place a venture is deliberate and the intention is to stop dangers when finishing up the venture and to safe the brand new setting.16 It can also be attainable to carry out a PRA on a number of domains of dangers so far as they concern the identical exercise.17

As the venture of centralization of PN compounding on the pharmacy is deliberate, the PRA technique was chosen to investigate current and potential future dangers related to the entire PN administration course of from prescription primarily based on sufferers’ laboratory values till administration of the person PN. To outline the urgency for centralizing and the necessity of an motion plan awaiting the completion of this venture, the PRA was carried out for the 2 PN making ready websites to check the chance ranges. Results of this threat evaluation will assist to raised conduct and bonafide the venture and to implement the deliberate measures.18

Composition of the Working Group

The working group of 9 contributors comprised the chief pharmacist, the scientific pharmacist for the neonatology division, the accountable pharmacist for PN preparation, a pharmacy technician, a PhD scholar (pharmacist) moderating the PRA, the neonatologist liable for PN, the chief nurse of neonatology division, the chief nurse of the unit, and a scientific nurse.

Definition of the PN Management Process Steps

Following a brainstorming with all members of the working group through the first assembly, 9 principal matters have been outlined to explain the totally different steps of the PN course of:

1. Medical prescription

2. Transcription of medical prescription

3. Primary materials

4. Preparation hood

5. PN preparation

6. Analytical high quality management

7. PN administration

8. Documentation and traceability

9. Laboratory values

All 9 course of steps had been mentioned individually and one after the opposite to establish all attainable dangers associated to the duties composing the involved course of step.

Risk Quotation

All recognized dangers had been quoted individually by consensus of all working group members through the second assembly. This was finished as soon as for the dangers recognized for the neonatal division and as soon as for the pharmacy.

The evaluation of every threat was carried out by figuring out the extent of severity (S) as proven in Table 1 and the extent of chance (P) as proven in Table 2.17 The results of severity ranges in addition to the frequency of chance ranges have been outlined prematurely of the PRA by the working group following inner examples (eg, earlier threat assessments) and experiences.

Table 1 Level of Severity (S)

Table 2 Level of Probability (P)

The analysis of all dangers was finished by consensus concerning scientific and pharmaceutical facets of every threat unbiased on its nature.

Risk Evaluation

The criticality index (CI) of every threat was calculated by multiplying the quoted severity and chance. The acceptability of dangers was outlined utilizing the Pareto precept or 80/20 rule,19 which means that about 20% of most important dangers will should be targeted on to succeed in probably the most optimistic final result of the entire evaluation. Therefore, as proven in Table 3, dangers with a CI of 1–6 (inexperienced) had been outlined as “acceptable”, CI of seven–14 (yellow) had been dangers categorised as “beneath management”, and “non-acceptable” dangers had a CI of 15–25 (pink).

Table 3 Criticality Index (CI) and Level of Acceptability (Green: “Acceptable”; Yellow: “Under Control”; Red: “Non-Acceptable”)

Following this threat evaluation for the 2 preparation websites, the third assembly served to concentrate on all “non-acceptable” dangers of CI ≥ 15. For a few of these dangers, deliberate measures for enchancment already existed. In this occasion, a second evaluation was carried out precisely like the primary one together with the calculation of a hypothetical CI. The intention nonetheless being the identification of residual dangers and the necessity of a corrective and preventive motion plan (CAPA plan). For the remaining dangers with out an already deliberate enchancment venture, measures had been proposed however the corresponding dangers weren’t quoted once more.


1st PRA

In whole, 75 dangers have been recognized, 36 of which had been for the entire PN administration course of on the NICU and 39 dangers on the pharmacy.

The variety of dangers recognized for the 2 preparation websites are listed in Table 4. Several dangers had been the identical for the 2 websites however typically differed in calculated criticality. Risks in widespread had been for instance associated to the medical prescription what must be finished for each eventualities and what presents the identical dangers for the ultimate product and the affected person. An instance for dangers not in widespread are associated to the PN preparation as this step is sort of totally different between the 2 websites.

Table 4 Number of Risks for Each of the 9 Management Steps for Parenteral Nutrition

The CI distribution of all recognized dangers is proven within the following Table 5.

Table 5 Distribution of Criticality Index (CI) of Identified Risks

Comparison of Main Process Differences

The PN administration steps that considerably differ between the NICU and the pharmacy embody steps n° 4. Preparation hood, n° 5. PN preparation and n° 6. Analytical high quality management, for which the variations of CI are proven in Table 6.

Table 6 Comparison of Criticality Index (CI) Sums of Differing Management Process Steps

Focused Risks

The working group targeted on all “non-acceptable” dangers (CI = 15–25) following the Pareto precept. Therefore, the eye was delivered to 11 vs 6 dangers for the NICU and the pharmacy, respectively. Two of the 17 targeted dangers had been recognized as equal for each preparation websites (dangers associated to PN administration), which means that 15 totally different dangers of CI ≥ 15 had been additional mentioned (Table 7).

Table 7 Details of “Non-Acceptable” Risks with Criticality Index (CI) of 15 and Higher for the Neonatal Unit (NICU) and the Pharmacy (PHA)

2nd PRA

Table 7 particulars the dangers the working group targeted on to outline measures to cut back their criticality. The hypothetic threat evaluation was additionally carried out on these dangers following a brainstorming and an analysis of the potential affect of the deliberate and instantly attainable measures as detailed hereafter.

Medical Prescription

An enchancment measure from the NICU deliberate to be carried out shortly after the second PRA was a prescription kind (Excel sheet) together with an intensive calculation base for every kind of remedy (oral, intravenous, subcutaneous, and many others.) to be administered to their sufferers together with PN. This quasi-electronic prescription kind is the evolution of a preformatted medical order sheet that has been launched beforehand for remedy prescription apart from PN.20 It represents an essential step in direction of an entire digital prescription, a so-called computerized supplier order entry (CPOE) system. This measure hypothetically permits to cut back three dangers associated to the prescription step as proven in Table 8.

Table 8 Hypothetical Reduction of Criticality Index (CI) After Implementation of Planned Improvement Measures for the Pharmacy (PHARM) and the Neonatal Intensive Care Unit (NICU)

PN Preparation

Another enchancment measure throughout the preparation step that hypothetically permits to cut back the CI for threat 5.5. “Non-respect of procedures and auto-control” is the revision and software of ordinary working procedures (SOP) for the PN preparation on-ward in addition to new notices and data for the auto- and double-control.

PN Administration

Finally, the chance 7.1. “False infusion charge” of the administration step is perhaps lowered by sensitizing the nurses to the significance of the correctness of the infusion charge adjustment and to satisfy the requested double-control.

For the NICU, the second PRA lowered the variety of “non-acceptable” dangers from 11 to 7 and their cumulated CI from 187 to 165.

For the pharmacy, the variety of “non-acceptable” dangers had been lowered from 6 to five and the cumulated CI for these dangers sank from 102 to 94.

With these short-term enhancements, the full CI will be lowered from 386 to 364 (−5.7%) and from 360 to 352 (−2.2%) for the NICU and the pharmacy, respectively.

Long-Term Improvement Measures

Despite the above described as instantly attainable and deliberate enchancment measures, the working group outlined long-term measures to enhance the 15 dangers rated with a CI of 15 and better previous to the centralization of PN preparation on the pharmacy.

In whole, six totally different measures are imagined to have a optimistic impression on 14 of the 15 dangers. Only one threat (6.1.) will in all probability stay unchanged (CI = 15) as no measure for enchancment is envisaged, as a result of the NICU won’t be able to carry out analytical qc on-ward.

Hereafter, the six proposed enchancment measures are described:

Computerized Provider Order Entry (CPOE) System

A CPOE system together with calculation base and suggestion ranges, interfaced with an automatic preparation software will allow to safe the prescription step and to enhance all associated dangers (1.1.-1.4.). The threat “false labeling” which is expounded to the preparation step (5.1.) may even be lowered by producing labels mechanically and scanning the barcode of those labels to start out manufacturing.

Training and Standardized Protocols

During our PRA, the working group recognized that coaching and standardized protocols will have an effect on the dangers 4.1., 5.4., and 5.5. These measures, already in place for the PN course of, should be revised and harmonized.

High-Visibility Vest

The high-visibility vest, to be worn on the NICU throughout preparation and administration of PN, may scale back dangers associated to those two PN administration steps (5.3., 5.6. and seven.2.). This will permit neonatal employees dealing with PN to be simply identifiable and to not be disturbed when sporting this vest.

Standardized Nutritional Solutions

Standardized dietary options like customary glucose dilutions or standardized PN infusion luggage will drastically scale back the chance associated to the PN preparation on the ward (5.7.).

Backup Preparation Tool

The threat associated to faulty services for automated compounding on the pharmacy (5.2.) will probably be minimized by acquisition of a backup preparation software (BAXA EM 2400).

New Infusion Pumps

New infusion pumps exactly programmable and clearly displaying the infusion charge may have a huge effect on this threat associated to the administration step (7.1.).


Even although a number of threat assessments have been carried out on the parenteral vitamin (PN) processes,15,16,21–24 the novelty of our work is the comparability in dangers of two websites throughout the identical hospital which are concerned within the strategy of PN for neonatal sufferers.

The preliminary threat analyses (PRA) carried out on the administration strategy of PN for the neonatal intensive care unit (NICU) and the pharmacy confirmed that many of the dangers are associated to the medical prescription, the PN preparation and the PN administration. Corresponding statements had been lately reported by Palmero et al for our NICU.25 The AMELIORE research carried out by Boulé et al recognized the identical course of steps as principal sources of dangers by performing a failure mode, impact, and criticality evaluation (FMECA).26 Our outcomes additionally correlate with these of Villafranca et al who carried out a failure mode and results evaluation (FMEA) on the neonatal PN course of from the attitude of the hospital’s pharmacy.27

Bonnabry et al had been the primary to carry out a FMECA on PN order and compounding to check the handwritten prescription with a computerized supplier order entry (CPOE) system in addition to the handbook with the semi-automatic compounding method.15 They repeated their threat evaluation on the CPOE system some years later to usually enhance the high-risk prescription strategy of every kind of medicines together with PN.22 In our research, the implementation of a CPOE system together with affected person information, dietary suggestions (ESPGHAN/ESPEN/ESPR pointers), calculation base and error alerts in addition to an interface with the automated preparation software (BAXA EM 2400)9 will probably be crucial measure to enhance a number of recognized dangers.

The NICU who plans to implement a quasi-electronic prescription kind (Excel sheet), is already conscious of some deficiencies inside their course of and is going through them actively whereas awaiting the centralization of PN preparation on the pharmacy. An actual CPOE system for PN prescription will probably be a standard software for NICU and pharmacy and is understood to enhance the prescription and transcription course of.28

Another research described that PN preparation error charges at pharmacies decreased from 37% to 22% when the method was partly automated. Most of those errors included mistaken dose (>3%) of parts of PN resolution or noticed omission.4 We additionally confirmed in a earlier article that 34% of PN ready manually by nurses on the ward didn’t conform to their medical prescription (Pharmacopoeia focus limits for compounded preparations: 90–110%) and focus of substances ranged from 58% to 164% primarily based on their goal worth (=100%).8

Following our assessments, measures to standardize the PN preparation course of had been proposed to face these dangers as really helpful by the American Society for Parenteral and Enteral Nutrition ASPEN.29 As quick motion till the whole take-over of compounding on the pharmacy, standardized PN preparation protocols for the NICU should be reviewed and utilized.

At the identical time, a regular ready-to-use PN resolution is in growth to furnish quick dietary therapy for new child time period and preterm infants as really helpful by the ESPGHAN pointers30 and practiced throughout France.31 The provide with a standardized PN resolution for neonatal sufferers gives a protected, high-quality, and ready-to-use different to individually compounded PN and subsequently reduces the variety of PN needing to be ready beneath unsafe circumstances.

PN administration security can principally be influenced by the neonatal caregivers by the straightforward measure of patient-focused (high-visibility vest) management of correspondence of remedy and medical prescription, infusion bag meeting and pump information entry following customary administration procedures as recommended within the ASPEN pointers. They additionally advocate to “buy infusion pumps with capability to cut back errors resulting from incorrect programming” which was contemplated in the intervening time of our threat assessments.32

Most of the dangers quoted with a criticality index (CI) of 15 and better (“non-acceptable”) probably resulted both in microbial contamination of the product or in a false dose of the totally different parts which means under- or overfeeding of the affected person. The penalties of false doses will be eradicated by analyzing the composition (glucose, Na+, Ok+, Ca2+, Mg2+) of the compounded PN earlier than administration as already carried out on PN ready by the pharmacy.33,34 Potential contamination may also be analyzed by way of endotoxin testing on pharmacy compounded PN.

Our threat assessments present that the entire course of is barely safer when the pharmacy is concerned within the administration of parenteral vitamin for sufferers handled on the neonatal ward (whole CI of 386 for the NICU vs 360 for the pharmacy). For the entire course of, 36 vs 39 dangers have been recognized for the NICU and the pharmacy, respectively. The variety of dangers being increased for the pharmacy will be defined by the a number of steps and interventions on PN earlier than, throughout and after its preparation course of together with management of the medical prescription by pharmacists in addition to the analytical high quality of the ultimate product. The compliance to GMP pointers being necessary for the pharmacy however not for the NICU is another excuse for the distinction in variety of dangers and their citation.

When taking a look on the administration course of steps which are unbiased between the 2 websites, a transparent distinction in security will be noticed. The steps involved are the preparation hood, PN preparation and analytical high quality management. The CI of the 2 websites differ from 145 to 108 for the NICU and the pharmacy, respectively. This means a threat is 26% much less more likely to happen for the weak sufferers when PN is ready on the pharmacy in managed circumstances (class A hood in cleanroom class B) with an automatic compounding system by skilled pharmacy technicians and with analytical qc to show conformity of the PN preparation with the prescription.

Risks in regards to the steps of main materials, documentation and traceability, and laboratory values are kind of the identical for each websites, however don’t essentially have the identical prevalence (chance) or the identical impression on the system or the sufferers (severity). All these dangers had been quoted with a CI <15 and subsequently not thought-about as vital however as “acceptable” or dangers “beneath management”. They haven't been additional mentioned.

The residual high-quoted dangers, like hygienic points inflicting contamination of the ultimate product or of the infusion line and the venous entry, may persist even after centralization of PN preparation. These sorts of dangers are well-known and are tough to keep away from fully,35 however measures to regulate and reduce their chance are in place (NICU: coaching of website personnel; pharmacy: in course of contamination management, annual management of aseptic working method, endotoxin testing).

Our research confirmed the necessity of standardized pc assisted procedures for the PN administration course of to safe these high-risk merchandise for weak sufferers. This standardization is unbiased of the place of PN preparation. When PN must be ready by nurses on the ward resulting from an emergency, this PRA demonstrated that the sufferers are usually not unnecessarily in danger. Thus the PN preparation on the pharmacy ought to be most popular as there are extra measures in place to ensure the conformity of PN preparation to its medical prescription in addition to the microbial high quality.

Still, procedures of each websites (NICU and pharmacy) should be improved to additional safe the entire multiple-step PN administration course of while awaiting the centralization of PN preparation on the pharmacy.

All threat assessments are primarily restricted by their subjectivity of defining and judging dangers associated to well-known processes. Therefore, the working group is meant to characterize a large spectrum of professions and, in consequence, ought to be sufficiently giant. Professionals not figuring out the method add essential inputs to explain and consider attainable dangers. The lack of this enter causes a small limitation of our research since all working group members who participated in our PRAs knew the processes as a result of they work with PN routinely. Nonetheless, the experience of the working group was of nice worth to the research.

Another limitation of our research is that we didn’t distinguish dangers the place one or the opposite service doesn’t have affect on, as for instance the PN administration which will be influenced by the NICU-staff solely. This reality result in a kind of mix-up of the CI of the 2 PN making ready websites.


Our PRA demonstrated a possible discount of 26% within the threat of PN preparation errors when all PN are ready centrally on the pharmacy, in comparison with the prevailing hybrid mannequin of NICU and pharmacy preparation when specializing in the principle differing steps (preparation hood, PN preparation, analytical high quality management). Although we thought-about NICU preparation as helpful for providing a speedy and adequately protected PN preparation course of, the potential security enhancements we recognized in our PRA outweigh these advantages for this weak inhabitants. All working group members in addition to the heads of the involved departments (NICU and pharmacy) agreed that this hybrid mannequin is now not the cutting-edge and should be revised quickly.

Ethics Statements

No evaluation or approval was required for this analysis by an institutional evaluation board or ethics committee as no intervention on people was carried out and no affected person information was analyzed and examined.


The authors report no conflicts of curiosity on this work.


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