This study describes errors associated with parenteral nutrition submitted to the Institute for Safe Medication Practices Medication Errors Reporting Program. The majority of errors occurred during the compounding or dispensing and administration stages.

Technical skill requirements are an important emphasis of medical training. This commentary highlights the role of simulation in developing procedural competencies within the demands of internal medicine residency. The authors suggest that focusing on procedural experience rather than technical skill can help clinicians learn how to manage their time, build relationships, and be mindful of treatment risks throughout their careers.

Parenteral nutrition has the potential to result in patient harm if administered or prepared incorrectly. This commentary builds on a set of overarching recommendations to define competencies that enable the safe prescribing and delivery of parenteral nutrition. The model is designed to help organizations apply the suggestions in their particular care environments.

Previous literature has shown that safety culture and nontechnical skills (such as communication) can affect safety and clinical outcomes in patients undergoing surgery. This systematic review identified several interventions that demonstrated effectiveness at improving various aspects of surgical culture, including teamwork and communication. A past AHRQ WebM&M commentary discussed disruptive behavior as a contributor to safety issues in surgery.

The introduction of the Institute for Healthcare Improvement central line bundle into a surgical intensive care unit dramatically reduced the incidence of central line–associated bloodstream infections, preventing an estimated 2.5 deaths per year in this single unit.

This commentary describes strategies to promote the use of parenteral nutrition safety guidelines in practice. The authors include examples of how checklists can improve adoption of best practices and discuss the potential for instituting policies and providing information about drug shortages to drive integration of the recommendations into daily work.

This publication outlines practice recommendations to prevent errors associated with parenteral nutrition.

Discussions on why humans err are central to safety improvement, but the concept isn’t universally accepted as an approach to determine the foci of how failure occurs. This commentary summarizes challenges to the use of the term “human error” while considering its usefulness in the context of organizational and social discussion of accidents.

Clinician decision support systems (CDSS) hold great promise as a means of promoting appropriate care, reducing diagnostic errors, and minimizing medication prescribing errors. However, a recent systematic review found that, taken as a whole, decision support systems achieved only small changes in provider behavior. In this study, a custom-designed CDSS that focused on preventing excessive medication dosages was implemented within a computerized provider order entry system, and resulted in a significant reduction in prescribing errors. Clinicians accepted one in four of the CDSS warnings—a seemingly low proportion that is, in fact, much higher than response rates found in many prior studies of drug alert warnings. The system was carefully tailored to be integrated into provider workflow and to provide only patient-specific warnings, factors that likely contributed to its success.

Approximately 1 in 60 prescriptions for parenteral nutrition resulted in a medication error, most of which occurred at the preparation or administration stages.