Background Paediatric total parenteral nutrition (TPN) for use in the neonatal intensive care unit is compounded by an external aseptic manufacturing unit. The manufacturing unit requires all prescriptions to be received before 10:30. A pattern in regular delayed TPN orders was noted. TPN prescriptions received after 10:30 resulted in afternoon manufacture and night delivery. Patient safety issues were identified in the prescribing and checking of TPN under tight time constraints and in late TPN administration.

Purpose To ensure all paediatric TPN prescriptions are ordered in a safe and timely manner.

Material and methods Institute of Health Improvement (IHI) methodology¹ was used to complete process mapping and to create a driver diagram. Secondary driver changes were made to the TPN prescribing and checking process including:

1. Neonatal blood to be completed at the end of the night shift instead of the day shift.

2. Laboratory to prioritise neonatal bloods on-call instead of waiting for the laboratory to open.

3. A switch in prescriber duty from the day shift to the night shift paediatric registrar.

Data were collected in three stages; pre-intervention (baseline) data, post-intervention data following secondary driver changes and re-audit data collected 12 months after the secondary driver changes.

Results Pre-intervention data showed that 44% of TPN orders were made before 10:30. Each prescription had an average of 1.85 queries. Post-intervention and re-audit data showed that 80% and 100% of orders were made before 10:30, respectively. Post-intervention prescriptions had an average of 0.87 queries and re-audit data had an average of 1 query per prescription.

Conclusion Implementation of multiple changes in process led to an increase in the number of TPN prescriptions received on time by the manufacturer. Patient safety has been enhanced by a reduction in late TPN administration and increased time to complete the ordering process. Repetitive queries were identified, which has led to the introduction of a prescriber-pharmacist communication sheet.

References and/or Acknowledgements

1. Institute of Health Improvement (IHI), 2014, IHI Open School- Driver Diagrams. Available at www.ihi.org (accessed 2 December 2014)

References and/or AcknowledgementsNo conflict of interest.