Parenteral nutrition (PN) is a high-alert medication that contains dozens of active pharmaceutical ingredients. This complex prescription drug preparation is used in a wide variety of clinical settings for patients across the age spectrum. Despite the existence of a number of guidance documents, the drug-use process for PN suffers from lack of standardization for order prescription, order verification and review, PN compounding, labeling, and dispensing. As a result, PN-associated medication errors would not be unexpected but are documented infrequently.