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PS-047 Medicines safety: the incidence and severity of prescribing errors in parenteral nutrition in paediatric inpatients
  1. T Hermanspann1,
  2. T Orlikowsky2,
  3. M Schoberer2,
  4. A Eisert1
  1. 1University Hospital of the RWTH Aachen, Pharmacy, Aachen, Germany
  2. 2University Hospital of the RWTH Aachen, Paediatric Clinic, Aachen, Germany


Background Parenteral nutrition (PN) is important for providing sufficient food for neonates, especially premature infants. Individually prescribed PN addresses specific patient requirements.1 Due to the diversity and complexity of PN prescribing, medicines errors may occur.2

Purpose To identify the incidence, type and severity of prescribing errors in PN in a paediatric intensive care unit (PICU). In this context the role of a clinical pharmacist should be checked as a member of an interdisciplinary team.

Material and methods The occurrence of prescribing errors in PN in a PICU in a university hospital was analysed retrospectively between March 2012 and July 2013. First the errors were categorised in seven pre-defined categories. Afterwards the potential severity of each individual error was assessed independently by three medical experts from three different Level III neonatal units, not involved in any treatment regimen and blinded for patient outcome, based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorising Medicines Errors.3

Results 118 prescribing errors were identified from 2,889 PN orders. Each error had been discussed and eliminated before preparing the PN, so no errors reached the patient. The majority of errors constituted the category ‘concentration range’; 65%. Nearly 11% of the errors occurred in the categories ‘dose’ and ‘indication’. Error rates of 5% and lower were due to ‘choice of drug’, ‘compatibility’, ‘patient data’ and ‘osmolarity’. (By using the NCC MERP Index, the three experts classified the errors into several categories.)

Conclusion These results underline that clinical pharmacists can prevent minor as well as major adverse drug events. Physicians as well as clinical pharmacists have to be aware of these risks and have to implement strategies to enhance medicines safety in PN treatment.


  1. 1,2,3 Literature available from the author

ReferenceNo conflict of interest.

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