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ISMP-A.S.P.E.N. Error Reporting Project

While Parenteral Nutrition (PN) and Enteral Nutrition (EN) are not traditionally thought of as medications, they are therapies that are prescribed, dispensed, administered, and monitored similar to medications. The administration of parenteral and enteral nutrition also involves the use of infusion devices that may be used in error (e.g., wrong type of device, incorrect programming of the device).

ISMP is collaborating with A.S.P.E.N., an organization dedicated to improving patient care by advancing the science and practice of nutrition support therapy, to educate clinicians about the benefits of reporting errors involving nutrition support therapy and associated devices and to learn about the types of errors as well as the causes and contributing factors the lead to these events.

The goals of this project are to:

  1. Educate healthcare professionals about reporting errors related to nutrition support therapy (e.g., what events to report, what information to include, and how to report them).
  2. Gather data from clinicians on errors involving nutrition support therapy and administration device and share this information with A.S.P.E.N..
  3. ISMP and A.S.P.E.N. will work on product and systems analyses of these errors and jointly publish and present findings from these reports.
  4. Develop educational material and strategies to reduce the risk of errors with the use of nutrition therapy.
  5. Collaborate on national initiatives that address risk reduction for nutrition support therapies.

To report errors involving nutrition support therapy, submit the event to ISMP on our error reporting page at

About A.S.P.E.N.
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is dedicated to improving patient care by advancing the science and practice of nutrition support therapy.  Founded in 1976, A.S.P.E.N. is an interdisciplinary organization whose members are involved in the provision of clinical nutrition therapies, including parenteral and enteral nutrition. With more than 5,500 members from around the world, A.S.P.E.N. is a community of dietitians, nurses, pharmacists, physicians, scientists, students and other health professionals from every facet of nutrition-support clinical practice, research and education.


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