Prevention of Transcription Errors with Pediatric TPN Orders Using a Web Interface

Transcription

1 Prevention of Transcription Errors with Pediatric TPN Orders Using a Web Interface Organization Name: University of Maryland Type: Acute Care Hospital Medical Center Contact Person: Belinda Todjo, PharmD Title: Pharmacy Mgr, Oncology Pharmacy and Women & Children s Pharmacy btodjo@umm.edu Phone: IDENTIFICATION: At the University of Maryland Medical Center, our pediatric TPN ordering system is a homegrown extensive and elaborate excel program. The program has built in features to check for osmolarity, calcium/phosphate solubility, dose range checking, able to account for total fluid intake and many more safety features. Our problem was that once the TPN has been entered into the excel program, a paper order is generated and is then manually entered into another computer system. This computer system/program is linked to an outside vendor who compounds the TPN. Our TPN vendor is Central Admixture Pharmacy Services (CAPS). Once the TPN paper order in entered into the CAPS TPN system, a duplicate label is generated and a second pharmacist independently double checks the label against the order. If an error is found, it is corrected and double checked again (see attached for TPN double check list). With the independent double check system, we still had transcription errors. We knew that there were no errors with the excel program but rather during the transcription from the paper order to TPN system. We wanted to explore ways that the excel program will interface with our TPN vender s system and to avoid the transcription portion of the process. PROCESS: We investigated to see what other interface programs were being used by other facilities that used CAPS as their TPN vendor. Our local and national CAPS representatives meet with the developer of our TPN order entry program (Dr Vinay) and pharmacy representatives to discuss what we were looking for, what was ideal and feasible. We would ideally like a process that would eliminate the manual transcription by pharmacy but at the same time, a process that would still require a pharmacist verification prior to the order being sent to CAPS for processing.

2 SOLUTION: The solution was to develop a web interface between the TPN order entry program and the CAPS TPN computer system. Basically, the provider will enter the TPN order on the unit, the order will be electronically transcribed to a web a based program where the pharmacist can review and approve the order, then at a specific time the order will be downloaded at CAPS for compounding. The first thing that needed to be done was to clean up the excel TPN program by building in additional allergies (in order to capture more), further defining upper and lower limits, configuring alerts and many other features. All the pharmacist double check components were also built into the excel program. The next thing was to build a program that would not only interface with the TPN excel program but also with the CAPS computer system. We employed a programmer who worked with Dr Vinay and the CAPS representatives to develop a secure web based interface. Once the web interface was built, we were ready to test all 3 features together (TPN excel program, web interface and transmission to CAPS). We entered orders on the excel TPN program, we reviewed how the orders transcribed to the web interface and developed a process for pharmacist verification and then finally we compared the original orders to the final labels that were generated at CAPS for compounding. We ran into a few issues but were able to quickly correct them. During the testing phase, we educated our pharmacists on the approval process, CAPS communicated to their front line team and we also educated our providers on the new process. In order to assure that our results were sustained over time, we created a spreadsheet where by the pharmacist checks off that all parts of the TPN has been received. The spreadsheet ensures that a paper TPN order from the TPN program has been received, the TPN appears in the web interface and that the TPN order is transmitted to CAPS. OUTCOMES: Although we were certain that the interface was working well after testing, we still had the pharmacists compare the paper generated TPN order to the web order during their verification process and prior to approving the TPN to be compounded by CAPS. We had our pharmacists continue this process for about three months to ensure that there were no errors made from the order entry point to the web interface. We did not have any reported errors from the order entry to the web interface; however, we were able to identify a few a things that we had to watch for. For example, the date of the TPN order has to be today s date or else it would not be captured on the interface. The interface will not capture a TPN order if there were special characters entered into the TPN program. Once we realized these issues, we communicated it to the providers and pharmacists. We have had no transcription errors since we implemented the web interface nearly a year ago.

3 TPN DOUBLE-CHECK CHECKLIST Name and MRN on order matches PharmNet label exactly (please be careful of twins & triplets). Date is today s date Weight and allergy information matches **(If the TPN is the first TPN for the patient, please double-check the weight and allergy in Pharmnet)** Volume and rate match and volume is not greater than 3000mls Line matches (central v. peripheral & w/ trace elements v. HOLD trace) Amino acid matches. (We have an exception to going over the 4% max of Trophamine for peripheral line which is the osmolarity < 1050 and an absence of either calcium or phosphate from the TPN. This policy was determined by Laura Wholberg and Elora Hilmas in consultation with Vinay Vaidya. Dextrose peripheral should not exceed 12.5%. Additives match the order NaCl + NaAc + NaPhos < 154meq/L of Na+ KCl + Kphos + Kac < Potassium limits (see below) PICU NICU General Floor Peripheral 80meq/L 60meq/L 60 meq/l Central 150meq/L Can exceed only with Attending signature 80meq/L 100 meq/l Can exceed only with Attending signature Calcium < or = 50meq/L Magnesium < or = 32meq/L Mulltivitamins added are appropriate for weight: Weight Amt MVI to add < 1kg 1.7 ml/day > 1kg and < 3kg 3.3 ml/day > 3kg 5 ml/day If the child is < or = to 2.5 kg, they receive a total of 400 mcg/kg/day of zinc (100 mcg/kg from trace elements mcg/kg extra).

4 If a patient weighs more than 15 kg and is ordered for trace elements, the label shows 3 ml next to MTE4-pediatric and 45 mcg selenium. If a patient weighs more than 15 kg and is ordered for trace elements separately, the label shows: zinc between 3 mg to 5 mg per order with 5 mg as maximum, selenium 45 mcg per order, chromium 3 mcg per order, copper 300 mcg per order, manganese 75 mcg per order. Routine adds for patients < 15 kg: selenium is 3 mcg/kg, L-cysteine is 40 mg/1 gm protein, and MTE-4 pediatric 0.2 ml/kg. Insure that the label shows 150 ml of overfill for pediatric TPNs and 100 ml of overfill for 6-Mother/baby and 7S L&D TPNs When Cu/MG is held, the amount of other trace elements is zinc 200 mcg/kg, selenium 3 mcg/kg, and chromium 0.2 mcg/kg. All zinc entries in the templates for > 2.5 kg have been set to default to a dosing method of mcg/order. Change to mcg/order for patients on the 5 th floor. This is particularly important for new starts. For adult patients, MVI 1 dose = 10 ml. MTE 1 dose = 3 ml. Fat Emulsions Pt weight < or = 1.2 kg 20% 50 ml bag All patients < or Pt weight 1.3 kg 4 kg 20% 100 ml bag = 1.2 kg who require Fat Emulsion will have a patient Pt weight 4 kg 14.9 kg Pt weight >= 15 kg 20% 250 ml bag 20% 500 ml bag specific bag ordered from CAPS. Check the Lipids section of the parenteral nutrition order to determine if a bag is required for the patient prior to processing. The order sheet is printed with the TPN order and requires a pharmacist check. Special Additives The following additives may be added to TPN with the following units of measure. Check original order for correct units before submitting and checking order.

5 Albumin Insulin (Adults) Iron Dextran Levocarnitine Phytonadione Ranitidine gm/kg/day units/day mg/kg/day mg/kg/day or mg/day mg/day (Add Q Monday for Adult TPNS) mg/kg/day