Improving Safety and Reducing Harm Associated With Specialized Nutrition SupportBrown Medical School and Rhode Island Hospital, Providence, Rhode Island Correspondence: Marion F. Winkler, MS, RD, LDN, CNSD, Rhode Island Hospital, 593 Eddy Street, NAB218, Providence, RI 02903. Electronic mail may be sent to mwinkler{at}lifespan.org. In 2000, the Institute of Medicine (IOM) estimated that medical errors in hospitals in the United States resulted in an alarming 98,000 deaths per year.1 The economic costs associated with errors are estimated to be $17–$29 billion annually.1 Life-threatening errors associated with the preparation and delivery of parenteral nutrition (PN) solutions have been reported. Data from the United States Pharmacopeia (USP) medication error reporting programs indicate that PN errors are low in frequency but have a high likelihood of causing patient harm. The incidence of patient harm associated with errors in PN is 18% compared with 14% incidence in harm for overall medications errors.2 The USP Medication Error Analysis reports that system breakdowns that occur during the prescribing, transcribing, and administering of PN lead to adverse events. An alarming 2519 errors associated with PN were recorded between August 1998 and August 2003.2 Twenty-one percent of the errors involved prescriptions, 36% were due to administration, and 14% resulted from transcription errors. Many of the reported incidences occurred in neonates and children. PN errors have led to extended length of hospitalization or rehabilitation, higher medical costs related to treatment of adverse events, life-threatening complications, and death. The provision of specialized nutrition support should occur in a manner that minimizes harm to the patient, promotes interdisciplinary care and management, improves nutrition status, prevents nutrition-related complications, decreases morbidity and mortality, and reduces costs associated with errors. Safety can be improved through interdisciplinary management; coordination among patient information, pharmacy management, and nutrition systems; elimination of handwritten orders to reduce errors associated with prescriptions and orders; and system checks to avoid inappropriate dosing and nutrition solution incompatibilities. The Joint Commission on Accreditation of Hospitals and Health Care Organizations (JCAHO) has formulated National Patient Safety Goals to promote specific improvements in patient safety.3 These goals highlight problematic areas in healthcare and describe evidence and expert-based solutions to these problems. The 2006 Disease-Specific Care National Patient Safety Goals can be reviewed at the JCAHO website (www.jcaho.org). Many of the national patient safety goals relate to the delivery and management of specialized nutrition support. These include:
Measures to improve the safety of PN have been published by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N).4 Guidelines can be found at www.nutritioncare.org. Other aspects of specialized nutrition support are considered high risk and are prone to complications. A report of procedures within US hospitals in 1997 indicated that enteral nutrition and PN are among the procedures associated with the largest number of in-hospital deaths, longest hospital stays, and highest inpatient mortality (16.9%).5 Although this may relate to the severity of illness and acuity levels of patients requiring nutrition support, it highlights the importance of focusing on patient safety and improving overall delivery and management of this complex therapy. Central venous catheter–related infections also lead to increased health care costs. An earlier review estimated that an episode of local catheter-related infection leads to an additional cost of approximately $400, whereas the additional cost of a catheter-related bloodstream infection (CRBSI) ranges from about $6005 to $9738.6 This issue of Nutrition in Clinical Practice highlights the importance of nutrition support safety and quality assurance. Each of the articles focuses on important aspects of the nutrition care process and provides the reader with evidence-based reviews and current practice guidelines for safe and efficacious care. Bankhead et al discuss the morbidity and costs of surgical, endoscopic, and laparoscopic gastrostomy procedures.7 Advances in enteral access devices, including current and future research and development of new materials for durable and safer percutaneous endoscopic gastrostomy (PEG) tubes, are described by DeLegge and DeLegge.8 Data reported by Krzywda and Andris, in their outstanding review of vascular access, indicate how implementation of evidence-based guidelines from the Centers for Disease Control and Prevention (CDC) can prevent or reduce CRBSI in central venous access devices.9 Prevention and management of metabolic complications are essential for the provision of optimal and safe nutrition support. Using case study illustrations, Dickerson provides a thorough discussion of the evaluation, treatment, and prevention of dehydration in patients receiving long-term tube feedings.10 Kraft and colleagues present science-based and clinically relevant guidelines for the treatment of electrolyte disturbances and for avoiding the refeeding syndrome.11 Data from the A.S.P.E.N. Safe Practices Task Force survey in 2003 revealed great variance in practice related to PN.12 More than half of the responders (54%) had a performance-improvement program to monitor appropriate use of PN, accuracy of orders, metabolic complications, and catheter and infectious complications. Only 29% of responding organizations were using computerized physician order entry (CPOE) systems for PN orders. The decline in the number of hospitals with formal nutrition support teams13 is unfortunate, given the alarming reports of PN medication errors, the increased costs of CRBSIs, and the association of enteral nutrition and PN procedures with length of hospital stays and hospital deaths. The articles in this issue of NCP illustrate the importance of evidence-based guidelines in the management of patients receiving specialized nutrition support. These articles offer clinical practice recommendations for enteral access device insertion and management, central venous catheter care, and metabolic monitoring that promotes safe nutrition support. Information technology is considered to be an important agent for change with respect to improving patient safety in health care. CPOE offers a potential solution for not only improving nutrition support prescription orders associated with illegible or incomplete handwriting but also for linking to standardized order sets and clinical decision support in which the prescriber receives immediate feedback at the time of order entry regarding possible incompatibilities, interactions, dosing errors, clinical alerts, and patient-specific data that might affect the order.14 Despite the documented benefits of CPOE in improving efficiency, legibility, and accuracy of orders, only a small number of hospitals have implemented CPOE systems, and presumably an even smaller number have included PN order writing as part of the system.15 The Agency for Healthcare Research and Quality (AHRQ) supports information technology initiatives designed to improve the safety of patient management systems and promotes and funds projects that identify the causes of preventable medical errors; develop, demonstrate, and evaluate strategies for reducing errors and improving patient safety; disseminate effective strategies throughout the health care industry; and evaluate informatics applications.16 Opportunities exist for nutrition support practitioners and organizations to develop clinical decision support tools, computer simulation for training, and autodata mining surveillance systems. As A.S.P.E.N. approaches its 30th anniversary, we must reevaluate how we, as individual practitioners and as an organization, can work collaboratively to incorporate clinical informatics as a resource for all healthcare practitioners and promote the interdisciplinary nutrition support team as a solution for patient safety, quality care, and controlled costs.
Nutrition in Clinical Practice, Vol. 20, No. 6,
595-596 (2005) This article has been cited by other articles:
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