Improving Pediatric Outcomes through Intravenous and Oral Medication Standardization

Parenteral Nutrition

Ordering, compounding, and verification of parenteral nutrition (PN) is a complex process.3 Pre-printed order forms help prevent omission and some communication errors but do little for calculation, transcription, and compatibility errors. Using computerization we were able to eliminate the pre-printed order forms and provide solutions for calculations, transcription, and compatibility errors. Our nutrition support team met with the hospital's computer programmer and developed the first known computerized prescriber order entry (CPOE) for pediatric PN. The CPOE was developed electronically in such a way that the order is checked for accuracy, dosage correctness, physical and chemical compatibilities, and provides necessary information to solve any unacceptable problems. The CPOE order was interfaced into an automated compounding device with barcode ingredient checks, decreasing the risk of human error in ordering, transcribing, and compounding. Safety and computer interface procedures were researched and developed to allow pharmacist approval prior to the order's electronic transmission. The computer program was developed with a decision tree for all PN ingredients, such as default standard ingredients, doses, and safe ranges for specific patient weights. Ingredient compatibility checks, especially calcium/phosphate compatibility ranges, were developed to prevent precipitation. Other additions to the PN program were total aluminum contamination concentration, barcoding the TPN label in order to ensure the correct patient order during automated compounding, and osmolarity calculations to avoid extravasation injury. End product testing of PN solutions through laboratory analysis was developed to assure the most accurate and safe compounding of glucose, sodium, potassium, calcium, magnesium, and phosphate. End product testing and refractive index were tested against the laboratory tested values for each PN and a paired sample t test was used to determine the compounding accuracy.

Intravenous Solutions (IVs)

After having success in improving and standardizing the complex PN process, it was concluded that the same principles could be applied to intravenous solutions. A program very similar to the previously described PN process was developed but simplified to accommodate commonly compounded IVs. This would allow the same electronic order transmission, automated calculations, automated compounding, and barcoding safety standardizations. This process would be used to determine the time reduction to intervene with IV ordering and clarification prior to compounding. We will determine the reduction in time for compounding and the improvement in turnaround time.

Drip Compounding

In 2002, prior to the Joint Commission National Patient Safety Goal, our institution changed from weight-based individually compounded drips to standard concentrations used on “smart” syringe pumps. This took a large interdisciplinary group that included intensivists, nurses, neonatologists, pharmacists, anesthesiologists, and many others over one year in planning and evaluation. It was a paradigm shift in how drips were ordered, manufactured, and administered. The hope was that the change would decrease the number of steps in the process, resulting in a decrease in errors. Concerns about giving too much fluid volume, especially in neonates, were addressed and monitored closely. We surveyed other pediatric centers and did “mock” conversions in order to determine the appropriate concentrations. We also used manufacturer-provided concentrations whenever possible to decrease the risk of compounding errors.

Standardizing Oral Liquids

Providing standardized liquid medications within predetermined dosage ranges has not been the standard of practice in pediatrics. Instead, the practice is to multiply the patient's weight by the dose requirement and then round the dose to an appropriate number. These results in a large number of individual doses compounded for specific patients with an increased risk for error each time a separate dose is prepared. The large variation in pediatric weights was thought to be the reason that standardizing pediatric oral doses could not be done. It was hypothesized that pediatric weight-based dosing could be standardized into therapeutic dosing ranges by developing a mathematical formula that allowed for weight-based dosing within therapeutic ranges, resulting in a reduction of the total number of different doses, waste and the potential for error. In order to increase acceptance of this type of process, medications with a large therapeutic window and a low side effect profile were chosen, such as calcium carbonate and docusate. As practitioners felt increasingly more comfortable with the process, more medications such as furosemide and iron were added. Standardizing the oral liquid medications allows for standardization of compounding formulas. The end point of oral standardization was to standardize 80% of the oral liquids chosen. The recipes for making oral suspensions were also reviewed for potential standardization.

Parenteral Nutrition (12,000 solutions per year)

In conjunction with a multidisciplinary team, a computerized worksheet was developed in such a way that a PN order could be electronically processed and checked for dosing, incompatibilities, precipitates, caloric intake and volumes, osmolarity, and highlight dosing that may be inappropriate.4–6 (Table 1) Precipitates due to calcium and phosphate are identified for each solution and dosage changes suggested to eliminate the precipitate.7–10 (Figure 2) An educational window is provided to give appropriate suggestions when needed to maintain dosages within patient needs, such as bone accretion rates. The computerized worksheet acts as a computerized prescriber order entry (CPOE), and provides checking and teaching screens for each medication ordered. After pharmacy review, the CPOE data is transmitted to the pharmacy department where the order is barcoded into an automated compounder and prepared for patient use. Once complete the PN undergoes end product testing for glucose, sodium, potassium, calcium, magnesium and phosphorous concentrations.

View Figure

• Download as Powerpoint
• Download Figure

Table 1. Example TPN Ordering Worksheet

View Fullscreen

Going from a paper order to a computerized worksheet reduced calculation errors. Each PN required 60 calculations with an error rate of 7%. Most error calculations involved converting milliequivalents to milligrams or millimoles, and calculating the calcium/phosphate compatibility. Using computerized worksheets reduced the calculation error rate to zero. Prior to completing the calcium/phosphate compatibility curves, 1 to 3 PNs would precipitate weekly. Once the calcium and phosphate curves were automated, the incompatibility problem rate decreased to less than one per year. Knowing how to maintain chemical stability with the required elements added to the PN, one could maximize the calcium and phosphate to obtain appropriate bone accretion rates. The computerized work-sheets guide the practitioner by maintaining a calcium/phosphorous ratio (mg:mg) between 1.3–2.2:1 with weight-based doses.11–13 Prior to implementing the worksheet, the ratio was 0.4:1 and 15% of the patients showed osteopenia on x-ray. Knowing how to maintain solubility of calcium and phosphate in PN and using appropriate doses and ratios reduced the osteopenia occurrence to 2%.

Improvements in the ordering process allowed the clinical pharmacists to concentrate on patient-oriented care (appropriate nutrition and disease state management) rather than task-oriented issues (incompatibilities, compounding, and order transcription). Changing to the computerized worksheet lead to a paradigm shift in clinical practice. Originally the pharmacists spent 80% of their time performing calculations and determining compatibility of the PN. After making the change the pharmacists now spend 10% of their time in calculation and compatibility and 70% in patient-oriented care. Once the pharmacists had more time to devote to optimizing patient-oriented care, it was noted that patients receiving PN and povidone for line change or surgery preparation had elevated urinary iodine levels, resulting in increased monitoring and decreased iodine dosage.14

End product testing was completed by comparing the calculated value against the laboratory analyzed value for sodium, potassium, calcium, magnesium, and phosphorous. Glucose concentration was determined by calculating the refractive index of glucose against the measured refractive index. The automated compounder was evaluated by comparing the calculated value against the pumped value. The PN was deemed correct if the calculated versus the laboratory values were within one standard deviation. A paired sample t test for the calculated and laboratory values was p= 0.000.

Intravenous Solutions (50,370 solutions per year)

Compounding sterile products is a critical function of pediatric pharmacy practice, and our institution compounds over 140 intravenous solutions daily. Applying the same concept of computerized worksheet to ordering intravenous solutions provided a sterile product that was accurate, compatible, and could be end product tested. Initially it was found that 15% of all IV orders required intervention before compounding. Using the electronic worksheet reduced the intervention rate to less than 1%, once again allowing the pharmacists to provide more patient-oriented care. Orders are entered on the worksheet and electronically submitted to the pharmacy where they are barcoded into an automated compounding machine. Using the manual process of compounding intravenous solutions required 35 minutes; converting to the worksheet reduced the time to 12 minutes, or a 64% reduction in turnaround time.

Drip Compounding (24,500 drips per year)

Thirty-two drips were standardized according to concentration, allowing for the elimination of the rule of six calculations and the implementation of “smart” pump technology.15–16 Once these 32 were incorporated into the “smart” pump library (Table 2), nursing staff only needed to enter each patient's weight and dose into the pump, eliminating the rule of six. Comparing the reported errors pre- and post-implementation of the standardized drips, the reported number of errors decreased by 73%. The reported error risk dropped from 3.1 to 0.8 per 1000 doses. Compounding errors made by pharmacy decreased from 0.66 to 0.16 per 1000 doses and the number of ten-fold errors decreased from 0.41 to 0.08 per 1000 doses. Standardized drug concentrations and “smart” pump technology reduced errors associated with continuous medication infusions.

Table 2. Medications Selected for Standard Drug Concentrations

View Fullscreen

Standardizing Oral Liquids (233,604 doses per year)

The mainstay for dosing oral liquid medications in pediatrics is based on each patient's weight. Using standardized doses improves patient care by reducing errors and promoting medication safety and control; additionally, it allows for medications to be placed in automated devices.17 A mathematical process was developed to standardize medications into therapeutic dosing ranges. Eleven medications were chosen, comprising 80% of the oral liquid medications dispensed in our facility (19,467 doses per month). The 11 medications required 329 different weight-based doses. Standardizing the doses reduced the number of different doses to 59, a decrease of 83%. Evaluating the standardization of iron, 1,732 doses were prepared monthly from 42 different milligram amounts. Standardizing iron reduced the different doses to 5 standardized doses, a reduction of 88%. (Table 3) Standardized dosing reduced the workload hours by 15% and reduced wastage by 90%. The overall compliance increased from 15% to 86% and resulted in cost savings of $15,000 per year. The number of errors was not tabulated but it was noted that there was a perceived reduction in error rate, and turnaround time decreased by 32%. Standardizing oral liquids as individual doses also lead the project to document over 100 recipes into standardized compounding formulations. These formulas are used in 22 hospitals, more than 100 clinics, and in conjunction with a CPOE outpatient prescription program.

Table 3. Example of Oral Liquid Dosage Standardization

View Fullscreen