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Learn strategies to safeguard use of the intravenous administration products to protect patients.
Several errors and work-arounds related to shortages of parenteral nutrition (PN) components have been reported to the Institute for Safe Medication Practices (ISMP). In some instances, organizations have been forced to reduce the number of days they provide PN to patients in an attempt to conserve resources.
For example, rather than providing daily nutrition, an organization reported that it had to reduce the administration of PN to 3 times per week. In other cases, organizations elect to use alternative products, such as multichamber bag parenteral nutrition (MCB-PN), for select patients instead of patient-specific compounded PN.
MCB-PN products are commercially available in various standardized compositions; they are available in 2- or 3-chamber bags. Clinimix and Clinimix E (Baxter) are available with 2 chambers. Clinimix comes with one chamber containing amino acids and the other containing dextrose, and Clinimix E comes with one chamber containing dextrose with calcium and the other containing amino acids with electrolytes. Kabiven and Perikabiven (Fresenius Kabi) are also available, with 3 chambers holding amino acids/electrolytes, dextrose, and lipids. For all MCB-PN products, the seals that separate the chambers must be broken, and the chamber contents must be mixed to ensure complete activation prior to administration. Although these products require fewer compounding steps, additives may still need to be added to these products in a sterile environment.
Some of the error reports submitted to the ISMP involved mix-ups between MCB-PN products. For example, during a shortage of PN compounding ingredients, an organization purchased Clinimix E 4.25/10 (dextrose with calcium and amino acids with electrolytes) and Clinimix 4.25/10 (dextrose and amino acids without electrolytes). The organization reported multiple errors in which the wrong formulation was dispensed, which was attributed to similar-looking packaging and staff unfamiliarity with these products. Other events were related to the failure to activate the bags. This resulted in the omission of certain components of the PN, such as calcium and dextrose. The ISMP has previously shared similar errors and actions to take to ensure the proper preparation of MCB-PN products.1,2
Organizations that have purchased or are thinking about purchasing MCB-PN products should consider the following risk-reduction strategies:
References
1. Pharmacist supervision is critical for proper preparation of Clinimix multi-chamber bags. Institute for Safe Medication Practices. October 21, 2010. Accessed November 15, 2022. www.ismp.org/resources/pharmacist-supervision-critical-proper-preparation-clinimix-multi-chamber-bags
2. Proper preparation of multi-chamber bag. Institute for Safe Medication Practices. March 10, 2011. Accessed November 15, 2022. www.ismp.org/resources/proper-preparation-multi-chamber-bag
About the Author
Michael J. Gaunt, PharmD, is senior director for error reporting programs and editor at the Institute for Safe Medication Practices (ISMP) in Horsham, Pennsylvania. He also serves as the editor of the monthly ISMP Medication Safety Alert! Community/AmbulatoryCare newsletter.