Administration of parental nutrition is a specialized process that requires distinct competencies to be safe. This guideline recommends standardized competencies for clinicians to develop and maintain to ensure safe and reliable administration of parenteral nutrition therapy in various care environments and team configurations.

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.

Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.

Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.

Previous studies have explored safety issues related to parenteral nutrition processes, but problems associated with general nutrition for inpatients have received scant attention. This commentary advocates for promoting awareness around malnutrition as a hospital-acquired condition and outlines 12 actions to improve the safety of nutrition care for hospitalized patients, including use of routine assessments and checklists.

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.

Redesigning tubing connectors according to new ISO standards has the potential to reduce tubing misconnections. This commentary provides information about changes to enteral connectors to prepare clinicians to use the new devices in their organizations.

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 commentary describes best practices for safe medication use and how to integrate them into daily care delivery.

This commentary describes how patient safety concepts, such as root cause analysis, safety culture, and health care failure mode and effect analysis, can enhance safety in dental care.

Analyzing published case studies on tubing misconnections and expert recommendations for improvement, this review suggests that equipment redesign—making enteral and IV systems incompatible—is the most effective strategy to reduce incidence of such errors.

A 2006 Institute of Medicine report highlighted growing concerns about the state of emergency department (ED) care, particularly around overcrowding and its impact on safety. Medication errors are a known safety threat, and this study provides a cross-sectional perspective using reports from the MEDMARX database. Investigators found that physicians were responsible for 24% of errors while nurses were responsible for 54%. The administration phase was the most error-prone, and the most common error type was improper dose/quantity. Interestingly, computerized provider order entry was noted to cause 2.5% of the errors reported. The authors advocate for future interventions to improve medication safety in the ED. A past AHRQ WebM&M commentary discussed a near miss medication error in the ED that illustrates the many safety issues that contribute to this high-risk care setting.

This commentary discusses how surgical care practitioners can protect patients from medication-related errors.

Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.

This study found that diuretics and antihypertensives were the most frequent medications reported in pediatric errors, and improper dosing was the most common type of administration error. However, error severity did not differ significantly by age or medication type.

This review surveys information on enteral nutrition administration and tubing misconnections and recommends employing increased standards and forcing functions to reduce their incidence.

This study describes characteristics associated with various tubing- and catheter-related errors, and advocates for educational opportunities to teach prevention strategies.

Analysis of MEDMARX data found that computerized systems did not prevent errors associated with dispensing and administering medications.