Introduction and Goals of the A.S.P.E.N. Parenteral Nutrition Safety Summit (2012)

During the past year, many circumstances and incidents have threatened the safety of parenteral nutrition (PN) as an important therapy. In light of the need to revise the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Parenteral Nutrition Safe Practice Guidelines and the need to publically address the safety of PN prescribing, formulating, and delivery, A.S.P.E.N. leaders have hosted a multiorganizational safety summit. The A.S.P.E.N. Parenteral Nutrition Safety Summit, held on September 23, 2011, brought together 46 key stakeholders to identify processes to improve the safety of prescribing, formulating, and delivering PN to patients across a variety of healthcare settings. The summit's purpose was to bring focus to PN safety issues and then develop action items and recommendations to make this therapy safer. The summit was endorsed by the Institute of Safe Medication Practices. Outline a systematic approach to prescribing, formulating, and delivering safe PN therapy. Describe unsafe incidents related to PN prescribing, formulating, and delivery. Identify processes and PN components most often related to incidents or PN errors. Recommend action items to improve the safety of the PN system and its components. Obtain a commitment from stakeholders to provide corrective action/measures in areas that influence PN safety. The focus of the summit was specifically on PN safety from a systematic approach. The content was on prescribing, formulating, and delivering PN. Administration issues were not included because of the limited time. The presentations provided descriptions of unsafe incidents in order to look at the processes as well as the components of PN that most often cause trouble. From these introductory remarks, the participants looked at the discussion points and issues to drive important recommended actions to make the system of PN safer. An important dimension of this summit was to engage the participants who were committed to attend but ask that the commitment be extended beyond this day to partnership with the practitioners, the industry members, and other organizations on future initiatives to make this therapy safer for our patients. The authors thank the Safety Summit Planning Task Force: Joe Boullata, Mike Cohen, Sharon Durfee, Beverly Holcombe, and Marty Kochevar; Paula Bowen for her administrative assistance; and Baxter International for its sponsorship. Jay M. Mirtallo, MS, RPh, BCNSP, FASHP, A.S.P.E.N. President and Director, MS in Health-System Pharmacy, The Ohio State University, College of Pharmacy Joseph Boullata, PharmD, RPh, BCNSP, A.S.P.E.N. Guidelines Editorial Board Member and Associate Professor, Pharmacology & Therapeutics, University of Pennsylvania, School of Nursing and Pharmacy Specialist, Nutrition Support Hospital of the University of Pennsylvania Angela Cassano, PharmD, President, Pharmfusion Consulting and member of American Society of Health-System Pharmacists Mike Cohen, RPh, MS, ScD, FASHP, President, Institute for Safe Medication Practices Mark DeLegge, MD, Professor and Director of Medicine, Digestive Disease Center; Medical Director of Nutrition, Medical University of South Carolina; and member of the American Gastroenterological Association Ian Deveau, PhD, Interdisciplinary Scientist, Acting Team Leader—Pharmacy Compounding Team, FDA/CDER/OC/OUDLC/DPD, U.S. Food and Drug Administration Sharon M. Durfee, RPh, BCNSP, Director, Poudre Infusion Therapy, LLC, and Representative of the Board of Pharmacy Specialties Jane Gervasio, PharmD, BCNSP, FCCP, Vice Chair and Associate Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, and A.S.P.E.N. member Elora Hilmas, PharmD, BCPS, Pharmacy Residency Coordinator, Nemours/Alfred I. duPont Hospital for Children Beverly Holcombe, PharmD, BCNSP, FASHP, Clinical Specialist, Department of Pharmacy, UNC Healthcare, and Chair, A.S.P.E.N. Shortage Subcommittee Eric Kastango, MBA, RPh, FASHP, Principal-CEO, Clinical IQ, LLC, United States Pharmacopeial Convention (USP) Gordon S. Sacks, PharmD, BCNSP, FCCP, Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy Auburn University, and Chair, A.S.P.E.N. CNW12 Planning Committee Deborah A. Andris, MSN, APNP, Colorectal Surgery Program, Froedtert/Medical College of Wisconsin, and A.S.P.E.N. Clinical Practice Committee Chair and JPEN Associate Editor Joan Bishop, Executive Director, The Oley Foundation Malcolm J. Broussard, RPh, Executive Director, Louisiana Board of Pharmacy, and President, National Association of Boards of Pharmacy E. Clyde Buchanan, RPh, MS, FASHP, Consultant: compounding sterile preparations and Representative of American Society of Health-System Pharmacists Charlene Compher, PhD, RD, FADA, LDN, Professor of Nutrition Science, University of Pennsylvania School of Nursing, and A.S.P.E.N. Clinical Guidelines Editor-in-Chief Mark R. Corkins, MD, CNSP, FAAP, Professor, Pediatrics Department, University of Tennessee Memphis, Children's Medical Center, and Chair, A.S.P.E.N. Pediatric Standards Praveen Goday, MD, MBBS, CNSC, Associate Professor, Medical College of Wisconsin, Pediatric Gastroenterology and Nutrition, and A.S.P.E.N. Board of Directors and Nutrition Committee, North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition Karl F. Gumpper, RPh, BCNSP, BCPS, FASHP, Director, Section of Pharmacy Informatics & Technology, American Society of Health-System Pharmacists Deborah R. Houston, PharmD, BCNSP, Clinical Program Coordinator, Advanced Home Care, and A.S.P.E.N. Clinical Practice Committee Member CDR Jouhayna Saliba, PharmD, CDER Drug Shortage Program, U.S. Food and Drug Administration Michael Kraft, PharmD, BCNSP, Clinical Assistant Professor, University Michigan College of Pharmacy; Clinical Coordinator, University Michigan Health System, Department of Pharmacy Services; and A.S.P.E.N. Pharmacy Practice Section Chair Ainsley Malone, MS, RD, LD, CNSC, Nutrition Support Dietitian, Pharmacy Department, Mt. Carmel West Hospital, and A.S.P.E.N. Vice President Lynne M. Murphy, RN, MSN, Consultant and Chair, A.S.P.E.N. Public Policy Committee Rick Osteen, DPh, Manager: Narcotics, Sterile, and Non-Sterile Compounding, Vanderbilt University Medical Center Melinda Parker, MS, RD, CNSC, National Clinical Director for Nutrition, Coram Specialty Infusion Services Steven W. Plogsted, PharmD, BCNSP, CNSC, Pharmacy Clinical Specialist, Nutritional Support, Nationwide Children's Hospital, and A.S.P.E.N. Clinical Practice Committee Lawrence A. Robinson, BS, MS, PharmD, Medical Communications, Inc, and A.S.P.E.N. Secretary/Treasurer David S. Seres MD, ScM, PNS, Director, Medical Nutrition and Nutrition Support Service, New York Presbyterian Hospital; Division of Preventive Medicine and Nutrition, Columbia University Medical Center; and Chair, A.S.P.E.N. Medical Practice Section Kelly Tappenden, PhD, RD, Professor of Nutrition and Gastrointestinal Physiology, University of Illinois at Urbana–Champaign, Department of Food Science and Human Nutrition, and JPEN Editor-in-Chief Beth Taylor, MS, RD, LD, CNSD, FCCM, Nutrition Support Specialist, Barnes Jewish Hospital, and Dietitians in Nutrition Support, a practice group of the American Dietetic Association Jamie Tharp, PharmD, Inventory and Distribution Pharmacy Manager, HomeMed, University of Michigan–Home Care Services, and National Home Infusion Association Patricia A. Worthington, MSN, RN, CNSC, Nutrition Support Nurse, Thomas Jefferson University Hospital, and A.S.P.E.N. Clinical Guidelines Editorial Board Peggi Guenter, PhD, RN, Director of Clinical Practice, Advocacy, and Research Affairs, A.S.P.E.N. Mary B. Baker, PharmD, Senior Medical Manager, Hospira Worldwide, Inc Susana Catelan, Director of Marketing Parenteral Nutrition, Fresenius Kabi North America Brent Eck, Executive VP, Frenius Kabi North America Mike Golebiowski, Product Director, Clinical Nutrition & Compounding Systems, B Braun Medical, Inc Caleb Hart, Marketing Manager, Infusion Therapy & Nutritional Products, Hospira Worldwide, Inc Todd Jones, CAPS Director of Marketing, B Braun Medical, Inc Phil Rackliffe, VP of Global Marketing, Baxter Inter-national, Inc Dennis Schneider Sr., VP of Marketing and Business Development, Baxa Corporation Dennis Tribble, PharmD, FASHP Chief Pharmacy Officer, Baxa Corporation Kurt Wehrle, Marketing Director, US Nutrition, Baxter Healthcare Corporation Supplementary data Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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