For their study, the Children's Center researchers first recorded a baseline total of 60 errors (10.8 per 100 TPN orders) from October through November 2000 that required the pharmacist to contact the provider to clarify or correct the order. After the paper-based TPN order system was replaced by the TPN Calculator, they saw just 20 errors from November to December 2000 (4.2 errors per 100 orders). Two years later, the error reduction rate soared to 89 percent, with just eight errors (1.2 errors per 100 orders) detected from August to October 2002.
The TPN Calculator computes all necessary fluid and component calculations, contains nutritional guidelines, and includes 62 rule-based alerts and reminders that prompt providers to review their information if any errors are detected. Lehmann says training takes an average of 10 minutes.
"This study demonstrates that it's possible to identify a situation with a potential for errors and use existing infrastructure to develop a practical, technological solution, while leaving aspects of the remaining system intact," Lehmann says.
The development of the TPN Calculator is one of many examples of the Johns Hopkins Children's Center's commitment to patient safety. In 2001, the Children's Center initiated its own pediatric patient safety program, "Safe and Sound," to proactively identify and remedy processes most vulnerable to human mistakes. The program is a collaboration of physicians, nurses, pharmacists, and allied health professionals and staff of the Children's Center, united with families in safeguarding the well-being of children and adolescen
Contact: Jessica Collins
Johns Hopkins Medical Institutions