National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system
National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system
Background: Parenteral nutrition (PN)–related patient safety incidents have been associated with harm. Large-scale studies are scarce, and little is known about contributory factors. This study evaluated PN-related incident reports that described harm using a national database. Materials and Methods: A retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death. Results: 12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors. Conclusions: This is the first evaluation of PN-related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high-risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.
medication, medication errors, parenteral nutrition, patient safety
1392-1408
Mistry, Priya
9b83e811-fa9f-4c01-986b-31c8ece1cccb
Fox, Andy
39222d91-d4b5-42e8-b46b-4702340f0f9e
Latter, Sue
83f100a4-95ec-4f2e-99a5-186095de2f3b
December 2023
Mistry, Priya
9b83e811-fa9f-4c01-986b-31c8ece1cccb
Fox, Andy
39222d91-d4b5-42e8-b46b-4702340f0f9e
Latter, Sue
83f100a4-95ec-4f2e-99a5-186095de2f3b
Mistry, Priya, Fox, Andy and Latter, Sue
(2023)
National evaluation of harm associated with patient safety incident reports related to the provision of parenteral nutrition to patients, using a national incident reporting system.
Nutrition in Clinical Practice, 38 (6), .
(doi:10.1002/ncp.10989).
Abstract
Background: Parenteral nutrition (PN)–related patient safety incidents have been associated with harm. Large-scale studies are scarce, and little is known about contributory factors. This study evaluated PN-related incident reports that described harm using a national database. Materials and Methods: A retrospective evaluation of incident reports involving PN in England and Wales reported to the National Reporting and Learning System between 2015 and 2020. We described frequency by degree of reported harm and incident characteristics. Content analysis was undertaken to understand contributory factors for reports related to moderate/severe harm or death. Results: 12,907 incident reports were identified. After screening, 2242 were evaluated; 1879 (83.8%) reported no harm, 309 (13.8%) low harm, 47 (0.02%) moderate harm, 4 (0.002%) severe harm, 3 (0.001%) deaths. The most reported age group, medication process, and error category were neonates (<28 days) (n = 570/1923, 29.6%), administration (n = 1126/2242, 50%), and omitted medication/ingredient (n = 291/2242, 13%), respectively. Content analysis of reports related to moderate/severe harm and death revealed patient age of <1 year, dependence on home PN (HPN), comorbidities, and staff errors as contributory factors. Conclusions: This is the first evaluation of PN-related incident reports in England and Wales to our knowledge. We demonstrated a low frequency of reports related to moderate or severe harm or death. More incidents were reported for neonates and during the administration processes. To reduce harm, systems/procedures that reduce errors in high-risk patients (eg, neonates, patients receiving HPN) need to be established within organizations. Database limitations of voluntary reporting systems were recognized.
Text
NCP-2022-12-444.R1_Proof_hi (1)
- Accepted Manuscript
More information
Accepted/In Press date: 13 March 2023
e-pub ahead of print date: 16 April 2023
Published date: December 2023
Additional Information:
Funding Information:
The authors thank the NRLS for providing the incident report data and their support throughout the data extraction process and for reviewing the final manuscript and providing feedback. Many thanks also to Joanne Turnbull PhD, Faculty of Health Sciences, University of Southampton, for support with managing the project during the challenges of the COVID-19 pandemic.
Keywords:
medication, medication errors, parenteral nutrition, patient safety
Identifiers
Local EPrints ID: 476787
URI: http://eprints.soton.ac.uk/id/eprint/476787
ISSN: 0884-5336
PURE UUID: ebbb41a2-221a-4e51-b2c4-763d9c1d80f1
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Date deposited: 16 May 2023 16:35
Last modified: 04 Jun 2024 01:36
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Author:
Priya Mistry
Author:
Andy Fox
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