SummarySeattle Children's Hospital adopted a standardized ordering and administration process for total parenteral nutrition—intravenous feeding provided to patients who are unable to obtain adequate nutrition from their digestive tracts—and shifted the role for prescribing total parenteral nutrition from physicians and residents to pharmacists to reduce errors. Pharmacists and dietitians now attend multidisciplinary rounds on every unit to assess the medication and nutritional needs of patients. Pre- and post-implementation analyses reveal a meaningful reduction in errors (from 9 to 2 per 1,000 total parenteral nutrition orders), less need for pharmacists to correct orders, a more efficient ordering and administration process, earlier delivery and administration of total parenteral nutrition, and increased staff satisfaction.Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including error rates, pharmacist error corrections, process time, TPN delivery time, and satisfaction survey results.
Developing OrganizationsSeattle Children's Hospital
Date First Implemented2005
Vulnerable Populations > Children
Problem AddressedThe ordering and administration of total parenteral nutrition (TPN) have been associated with high numbers of medical errors and increased risk of death, especially in pediatric patients. TPN is a complex formulation that involves 20 or more components; clinicians without adequate expertise can easily order and/or dose ingredients incorrectly.
- High numbers of errors: TPN ordering and administration are associated with high rates of medical errors and fatalities.1 For example, an analysis at one institution revealed that prescribing errors occurred in 27.9 percent of TPN orders, with pediatric residents being more than twice as likely as neonatal nurse practitioners to commit an error (39 percent versus 16 percent).2 Although there have been no TPN-related fatalities at Seattle Children’s Hospital, an average of approximately 9 errors per 1,000 TPN orders reached patients in 2004, with a monthly variation of 3.5 to 17.5. In fact, a 2004 analysis of the frequency, severity, and hospital-wide pervasiveness of adverse events at Seattle Children's identified TPN errors as the most critical high-risk medication error at the hospital.
- Driven by problems in ordering and administration processes: Errors are frequently the result of flaws in ordering and administration processes. For example, pharmacists at Seattle Children's expressed significant frustration with the TPN ordering process, with house staff routinely flooding the pharmacy with TPN orders near the noon deadline for orders each day. Many of these apparently rushed orders contained errors.
- Standardization as a way to reduce errors: The American Society for Parenteral and Enteral Nutrition recommends standardizing TPN processes (including ordering, labeling, screening, compounding, and administration) to improve patient safety, clinical appropriateness, and resource efficiency.3
Description of the Innovative ActivitySeattle Children's Hospital adopted a standardized ordering and administration process for TPN—intravenous feeding provided to patients who are unable to obtain adequate nutrition from their digestive tracts—and shifted the role for prescribing total parenteral nutrition from physicians and residents to pharmacists to reduce errors. Pharmacists and dietitians now attend multidisciplinary rounds on every unit to assess the medication and nutritional needs of patients. Key elements of the program include the following:
- Pharmacist and dietitian inclusion in patient rounds: A pharmacist and a dietitian join patient care rounds on all units so that the pharmacist, dietitian, physicians, nurses, patient, and family members can discuss the patient’s entire plan of care. The pharmacist reviews all pertinent medications, and the dietitian reviews nutritional needs, with TPN requirements integrated into those discussions. (Before the program's implementation, pharmacists and dietitians did not consistently attend patient rounds on all units.)
- Pharmacist ordering of TPN: When a patient requires TPN, the details of the order are discussed by the rounding team, and the pharmacist writes the order. (State regulations allow pharmacists to write these orders.) Previously, only the institution’s physicians and nurse practitioners could write TPN orders.
- Ongoing submission of orders: Seattle Children’s Hospital sends TPN orders to its offsite compounding pharmacy, which requires a noon deadline for order submission. Previously, due to house staff delays in writing complex TPN orders and the need for pharmacists to review/approve TPN orders, most orders ended up being backlogged and were not sent until just before noon. Under the current system, pharmacists send the orders to the compounding facility more evenly throughout the morning, beginning at 9 a.m. (usually with the most straightforward orders being sent first).
- TPN administration by unit nurses: Previously, the hospital’s intravenous (IV) nurses, who do not have responsibility for particular patients, were responsible for obtaining the TPN bags delivered to the hospital pharmacy and then administering them to general unit patients. (Floor nurses were responsible for administering TPN in the intensive care unit and on bone marrow transplant units.) Under the new system, TPN bags are delivered to a standardized location on each unit, and the unit nurses administer TPN to their own patients. As a result, IV nurses were redeployed to IV line placement (their specialty), thereby improving service and quality in that area of care.
- Checklist for TPN administration: The institution runs TPN as two separate infusions that are ordered and administered concurrently: one for amino acids (proteins) and carbohydrates and one for lipids. Each is infused at a different rate (with the lipid rate being approximately one-tenth the protein/carbohydrate rate). To avoid infusion rate and other administration-related errors, a checklist was created to standardize all aspects of TPN administration (e.g., line labels, documentation, tubing setup, pump setup, verification procedures). In 2011, a second RN check was added to the checklist process to improve safety.
Context of the InnovationSeattle Children's Hospital is a 250-bed academic medical center that offers pediatric care in 56 subspecialties and serves as the pediatric referral center for Washington, Alaska, Montana, and Idaho. Information provided in June 2012 indicates that the hospital handled over 14,000 inpatient admissions in 2011 and currently averages 33 TPN orders per day (17 percent of patient days). The program was developed using principles of the Toyota Production System, in response to the previously described 2004 study that found that TPN errors were a significant problem in the hospital, due in part to problems in ordering and administration.
ResultsPre- and post-implementation analyses reveal a meaningful reduction in errors, less need for pharmacists to correct orders, a more efficient ordering and administration process, earlier delivery and administration of TPN, and increased staff satisfaction.
Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including error rates, pharmacist error corrections, process time, TPN delivery time, and satisfaction survey results.
- Fewer TPN-related errors: TPN-related errors that reached patients fell from an average of approximately 9 per 1,000 TPNs (with monthly variation from 3.5 to 17.5) in 2004 to approximately 3 per 1,000 TPNs (with monthly variation from 1 to 6) in 2006. Information provided in June 2012 indicates that in 2011, TPN-related errors were approximately 2 per 1,000 TPNs (with monthly variation from 0 to 4).
- Less need to correct orders: The number of pharmacist interventions to correct TPN orders fell from 26 per 100 orders in 2004 to 6 per 100 orders in 2006. Information provided in March 2010 indicates that this number remained at 6 per 100 orders in 2009.
- More efficient ordering and administration: The number of steps involved in TPN-related processes fell significantly, from 77 to 6 steps for ordering, and from between 35 and 47 steps to 16 steps for administration. The number of handoffs involved in these processes fell significantly as well, from 8 to 2 handoffs for ordering and from approximately 3 (ranging between 2 and 4) to 2 handoffs for administration. The number of check (or "inspection") steps in the ordering process fell from 28 to 3, whereas the number of check steps in the administration process fell from roughly 9 (ranging between 8 and 10) to 5. The time involved in the ordering process fell from more than 6 hours (6:02) to less than 2 hours (1:58), while the time to administer TPN also fell significantly (from a range of 30 minutes to 2 hours and 40 minutes before the program to an average of 45 minutes after implementation).
- Earlier delivery and administration: The elimination of batched order submissions led to an hour earlier delivery of TPN (from 4 p.m. to 3 p.m.), which allows unit nurses to focus on TPN administration well before addressing reporting activities required before the 7 p.m. shift change.
- Improved staff satisfaction: Pre- and post-implementation satisfaction surveys administered to pharmacists, dietitians, and house staff indicate across-the-board increases in satisfaction with and confidence in the TPN process.
Planning and Development ProcessInitial analysis, redesign, and implementation occurred between February and July 2004; key elements of the planning and development process included the following:
- Collecting data: Institutional leadership collected data on a number of indicators, including TPN-related errors, measures of pharmacist workload related to TPN orders, and the amount of ordering and administration process time.
- Creating a multidisciplinary team: A team consisting of house staff and faculty physicians, nurses, pharmacists, and dietitians was convened to observe and redesign TPN-related workflow.
- Holding redesign workshops: The team applied Toyota continuous improvement principles during two workshops in which they redesigned processes for ordering, delivering, and administering TPN. (TPN preparing/compounding was not found to be a major problem).
- Obtaining prescriptive authority for pharmacists: The institution sought and obtained authority from the Washington State Board of Pharmacy to allow pharmacists to sign TPN orders.
- Training: Pharmacists were trained and credentialed to order TPN and the new process was explained to all staff.
- Pilot testing and rollout: The team implemented the redesigned processes for delivery and administration housewide. Several months later, the order process was implemented on the surgery unit; based on success, the new process was rolled out to all the units.
- Hiring new staff: The institution hired additional pharmacists and dietitians to ensure sufficient staff capacity for participation on daily rounds.
- Measuring and reporting performance, refining the process: The team collected and analyzed data to measure program impact, and made adjustments as needed. Performance data were shared across the organization by posting results on “Visibility Walls,” where information about hospital activities is displayed. The hospital also used its Intranet to highlight the reduction of TPN errors as an organizational goal and to illustrate progress toward that goal.
Resources Used and Skills Needed
- Staffing: Approximately 5 new full-time equivalents (FTEs), consisting of 2.5 FTE dietitians and 2.5 FTE pharmacists, were hired to ensure that a pharmacist and a dietitian could consistently participate in daily rounding. Information provided in May 2011 indicates that since 2006–2007, the hospital has increased its pharmacist FTEs in response to demand for dedicated services on additional patient care (rounding) teams. This has spread TPN writing responsibilities over a larger number of pharmacists but has not changed TPN ordering practices. The additional FTEs (above the 2.5 already noted above) are not directly attributable to the TPN program.
- Costs: The annual cost of the additional staffing is viewed as an investment in the reduction of complexity and process variation. Institutional leadership strongly believes that these additional expenditures are far outweighed by the benefits derived from error reduction, improved quality, and improved staff support.
Funding SourcesSeattle Children's Hospital
Getting Started with This Innovation
- Obtain executive leadership support: Leaders need to support the program, both from a cultural and financial/resource perspective.
- Sell clinicians and frontline staff by emphasizing potential for improvement: An organization-wide philosophy about continuous performance improvement helps facilitate staff support for change. In addition, data relevant to each stakeholder group can illustrate the need for improvement; for example, to convince relevant stakeholders of the need for change, Seattle Children’s Hospital presented data on ordering errors to the house staff and data on administering errors to the nurses.
- Be patient when prompting culture change: Transferring TPN order writing from the residents to the pharmacists represented a big culture change for the hospital, requiring some adjustment on the part of residents and significant effort on the part of the pharmacy staff.
- Phase-in program implementation: Rollout should occur as adequate staffing is brought in to support the program.
- Focus on overall nutrition, not just TPN: A patient's nutritional status is often overlooked, despite being an essential part of health and health care. Having a dietitian and a pharmacist participate on daily rounds as part of a coordinated team can improve the nutritional outcomes of all children in the hospital (not just those in need of TPN).
- Focus on the whole TPN process, not individual pieces of it: Consider the ordering, delivery, and administration of TPN, rather than focusing on only one aspect of the process.
Sustaining This Innovation
- Monitor performance on ongoing basis: A significant, organization-wide change will not occur without regularly reviewing results and sharing performance data so as to prevent a regression into old processes.
- Consider offering house staff education on TPN: Because house staff is no longer responsible for ordering TPN, the institution provided supplemental education to those physicians who desire additional expertise in the area. Online education modules are provided for house staff, and house staff can electively receive additional education for TPN ordering certification.
- Maintain focus: Information provided in June 2012 indicates that monitoring performance on an ongoing basis is critical for "holding the gains." In 2009, the hospital's slip in error reduction was caused by some drift in practice that has not been addressed in a timely manner. The hospital's willingness to refocus efforts on establishing standard work for medication administration has resulted in reclamation of initial gains and further reduction in TPN error rate.
Contact the InnovatorEric Harvey, PharmD, MBA
Seattle Children's Hospital
4800 Sand Point Way NE
Seattle, WA 98105
Phone: (206) 987-1990
Innovator DisclosuresDr. Harvey reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
Lehmann C, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator. Pediatrics. 2004;113(4):748-53. [PubMed]
Brown C, Garrison NA, Hutchison AA. Error reduction when prescribing neonatal parenteral nutrition. Am J Perinatol. 2007 Aug;24(7):417-27. [PubMed]
American Society for Parenteral and Enteral Nutrition. ASPEN Statement on Parenteral Nutrition Standardization. JPEN J Parenter Enteral Nutr. 2007;31(5):441-8. [PubMed]
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Original publication: March 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 13, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.