Patient safety notification issued on parenteral nutrition incidents

The clinical risk unit at the State Claims Agency (SCA) recently issued a patient safety notification on factors contributing to parenteral nutrition-related incidents.

A spokesperson for the SCA said the unit noted such incidents as part of its surveillance activity. It undertook a retrospective review of reports from a 12-month period during 2022 to early 2023.

Some 163 incidents occurred in hospitals and one in a community setting. None were rated as ‘major’ (ie, involving serious harm or death).

Factors that contributed to incidents included prescribing (eg, incorrect regimen); ordering and delivery (eg, not ordered/not ordered in time); administration (eg, incorrect infusion rates/times/bags; administered to wrong patients); and other issues such as disconnected infusion lines.

Parenteral nutrition is the intravenous administration of nutrition which bypasses the gastrointestinal tract. It may be total, where the digestive system is not functioning at all, or supplementary, where some intake via the digestive system is possible, but inadequate to meet requirements.

It is associated with several avoidable risks, which include infectious complications, catheter insertion complications, and metabolic complications. One of the most serious and avoidable complications is catheter-related infection.

The recent advice was prepared by the SCA in conjunction with the Irish Society for Clinical Nutrition and Metabolism. It stated that healthcare services should have in place – and adhere to – policies and procedures on the use of parenteral nutrition, including strict adherence to infection prevention and control measures.

All health and social care professionals should have the correct level of training on the use and administration of parenteral nutrition relevant to their setting prior to undertaking practice in this area. Services should undertake regular audit of the implementation and impact of guidelines.