Quality improvement programme reduces errors in oral medication preparation and administration through feeding tubes

Effectiveness of a checklist for enteral medication administration: A randomized controlled trial

BACKGROUND

Enteral nutrition protocols are used when oral nutrition is contraindicated. Medications may be administered through enteral feeding tubes when alternative routes of administration are not available. A brief review of the literature shows a lack of knowledge and inconsistent behaviours among nurses regarding enteral medication administration, which may pose a threat to patient safety.

AIM

This study was conducted to evaluate the effectiveness of an enteral medication administration checklist in reducing medication administration errors via enteral feeding tubes.

STUDY DESIGN

A randomized, controlled, triple-blind, experimental design was used. The study was conducted between 2022 March and June in five different intensive care units of a research and training hospital in X city, XX country. Sixty-nine volunteer nurseswere divided into two groups: intervention (n = 34) and control (n = 35) by stratified randomization method. The study was conducted in two steps. First, a checklist for enteral medication administration was developed according to the recommendations of the American Society for Parenteral and Enteral Nutrition, the European Society for Clinical Nutrition and Metabolism and the British Association of Parenteral and Enteral Nutrition. Second, the effectiveness of the checklist on the intervention group in reducing implementation errors was examined. Four data collection tools, including a descriptive information form, enteral medication administration evaluation form, knowledge assessment form and observation form, were used in the study.

RESULTS

In the pretest phase, the mean error rate of the control group was 37.49 ± 18.42, while in the intervention group it was 38.23 ± 15.08; in the post-test phase, the mean total error rate of the control group was 26.88 ± 17.56, and it was 2.21 ± 4.05 in the intervention group. Accordingly, it was determined that the post-test total error rate mean of the intervention group was statistically significantly lower than that of the control group (p < 0.05, t = -8.096 [-30.846; -18.502]).

CONCLUSION

The enteral medication administration checklist reduced errors in the administration of medications through enteral feeding tubes. Therefore, the checklist can be used to reduce errors in medication administration.

RELEVANCE TO CLINICAL PRACTICE

This study was conducted to reduce errors in enteral drug administration reported in the literature. With the developed checklist, these errors were reduced, and a standard practice approach was provided to intensive care nurses.

Medication Administration Through Feeding Tubes in a Tertiary Hospital: A Retrospective Observational Study

Aim

This study aimed to investigate the prevalence and types of errors associated with oral medication administration via feeding tubes (FTs) in a tertiary hospital in Beijing.

Methods

A retrospective observational study was conducted at Beijing Hospital between January 2018 and December 2022. All inpatients aged of 18 and above who received at least one oral medication via FTs were included. Medical records were meticulously collected and analyzed.

Results

A total of 7,243 patients were identified as part of the tube feeding group, representing a prevalence rate of 6.26% among hospitalized patients receiving oral medication. Compared to the general hospitalized population, patients in the tube feeding group exhibited a higher proportion of male patients (59.74% vs 48.91%), older age [(68.00±14.99) vs (59.75±16.38)], lower weight [(65.75±13.32) vs (67.82±12.72)], increased rates of being bedridden (18.06% vs 5.38%), longer hospital stay [(21.56±28.12) vs (8.88±10.38)], and a greater number of prescribed medication types [(51.21±19.37) vs (23.35±15.04)]. On average, patients in the tube feeding group were administered 8.92±6.78 types of oral medications. A significant percentage of patients in the tube feeding group experienced inappropriate medication administration, reaching 65.43%. Among these cases, the rate of inappropriate medication administration for patients receiving nasogastric tube and nasojejunal tube were 64.06% (4186/6535) and 78.11% (553/708), respectively. In total, there were 10,164 instances of inappropriate medication administration, averaging 1.40 times per patient in the tube feeding group. Inappropriate medications included enteric-coated drugs, modified-released, soft capsules, and other non-crushable drugs.

Conclusion

Our results Our findings highlight a significant issue of inappropriate medication administration via FTs. Ensuring the accurate administration of orally prescribed medications to patients with FTs is a complex task that requires immediate attention.

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

Development of an Administration Guideline of Oral Medicines to Patients with Dysphagia

Background and Objectives: There is increasing evidence that patients with dysphagia often have limited access to suitable oral dosage forms, especially when administered via an enteral feeding tube (FT). In addition, there is a lack of clear and readily available information from drug manufacturers on how to administer medications to patients with dysphagia. This study aimed to develop a practical guide for healthcare professionals to increase the safe and effective administration of oral medications to patients with dysphagia. Materials and Methods: The data were collected from existing English databases and handbooks available to develop an easy-to-use tabular guideline presenting all relevant information using keywords and short expressions. The working group differentiated 514 formulation types, and the information was collected and added to the guideline separately. In addition, the instructions for the patients taking the medicines orally or via FT were described separately. Results: The guideline consisted of 24 keywords or short expressions developed by the working group and described the instructions to use them. The guideline contained 343 active pharmaceutical ingredients and 19 fixed-dose combinations. Conclusions: Knowledge about proper medication preparation and administration for patients with swallowing difficulties is limited but essential. It is crucial to encourage drug manufacturers to provide this information as a standard to ensure the safe and effective use of medications for all patient groups.

Impact of a quality improvement programme on the preparation and administration of medications via a nasoenteral feeding tube: 2014-2019 intervention study

AIMS

Evaluate the impact of a quality improvement programme on the reduction of feeding tube obstruction frequencies, analyse the predictive variables of this safety incident, and estimate the economic costs related to the quality improvement programme during the period from 2014 to 2019.

METHODS

Plan-Do-Study-Act cycles were performed to test the changes in drug preparation and administration processes via a nasoenteral feeding tube and to evaluate the outcome, process and balance measures. Statistical control charts were elaborated, and the bottom-up direct costing methodology was used to estimate the costs of the improvement programme. The impact of the programme on the monitoring measures was evaluated using logistic regression analysis.

INTERVENTIONS

The following changes were tested in the hospital participating in the study: acquisition of the Easy Crush equipment for tablet crushing, use of appropriate packaging to crush hard tablets, standardise procedures for scheduling administration times and/or substitution of the pharmaceutical form, educational activities for the nursing team and elaboration and availability of infographics for the nursing team, patients and/or family/caregivers.

RESULTS

There was a significant improvement in the frequency of tube obstructions, from 41.1% in 2014 to 57.9% in 2015-2017 and 9.6% in 2018-2019 (p=0.0010). After the execution of the improvement programme, it was estimated that the cost of dose preparation was reduced from R$1067.50 in 2014 to R$719.80 in 2015-2017 and R$433.10 in 2015-2019.

CONCLUSION

By re-establishing the processes of drug preparation and administration via a nasoenteral feeding tube, through the acquisition of appropriate equipment for crushing hard tablets, together with educational activities for the nursing team, we could observe a reduction in tube obstructions and the cost of processes.

Solid oral medications' suitability for use in enteral feeding tubes

BACKGROUND

There is a lack of specific data about the efficacy and safety of medications administered via feeding tubes, although there is a general awareness that not all drug formulations are suitable.

AIMS AND OBJECTIVES

To overview the current situation with solid medications administered through feeding tubes in the Tartu University Hospital intensive care units. To evaluate the availability of information on the suitability of drug formulations for administration via feeding tubes.

DESIGN

This was a descriptive retrospective document analysis study.

METHODS

During visits to the intensive care units, medication data for current patients were collected from paper medical charts and nurses. In addition, package information leaflets, summaries of product characteristics, and two practical handbooks were used for evaluating the medicines' suitability for administration via feeding tubes. A request for information was also sent to manufacturers or marketing authorization holders.

RESULTS

In 3 months, data were collected from 113 intensive care patients' medical charts. A total of 306 medication administrations via feeding tubes were documented and analysed, 67% of which were solid oral dosage forms. Exactly 91.2% of these were conventional tablets. After the analysis of information availability, 88% of the medications were classified as suitable for administration via feeding tubes, but only 48% had the manufacturer-provided information.

CONCLUSION

This study showed that the information about the suitability of formulations administration through a feeding tube is not readily available for almost half of the medications. The manufacturers seem to have the relevant information, but it is not always added to their medications' official information, putting these patients at higher risk for errors.

RELEVANCE TO CLINICAL PRACTICE

This study shows that if there is no clear statement about administration through feeding tubes on official manufacturers' information, this should be sought directly from manufacturers or marketing authorization holders, and the data could be incorporated into local guidelines.

IMPACT OF PLAN-DO-STUDY-ACT CYCLES ON THE REDUCTION OF ERRORS RELATED TO VACCINE ADMINISTRATION

ABSTRACT Objective: to evaluate the impact of a quality improvement program in the reduction of errors related to vaccine administration. Method: an intervention study aimed at comparing outcome measures before (Phase I) and after (Phase II) the implementation of a quality improvement program. It was carried out in a Basic Health Unit in the inland of São Paulo from March 2019 to November 2019. In the first phase, there was direct observation by Nursing professionals during the preparation and administration of the doses. In the second phase, an error was selected and subjected to four Plan-Do-Study-Act cycles to test the changes. The following quality tools were also used: root cause analysis, Ishikawa diagram and Pareto diagram. Results: a total of 164 doses of vaccines prepared and administered to 51 users were observed; 527 errors were identified and categorized into 13 types. In 27.7% of the observations made in Phase I, the users/guardians were not informed about potential adverse reactions. The goal of 100% of guidelines was established over an eight-month period, which was achieved in the second Plan-Do-Study-Act cycle and maintained in the third and fourth cycles, with confirmed improvement in the process. Conclusion: the quality improvement approach, based on Plan-Do-Study-Act cycles, contributed to the reduction of errors in the administration of vaccines and the change was sustainable, as it maintained over time.

Factors associated with mechanical device-related complications in tube fed patients: A multicenter prospective cohort study

AIMS

To identify the types of nasogastric/nasoenteric tube (NGT/NET)-related adverse events and to analyze the degree of harm and the factors associated with mechanical device-related complications.

MATERIALS AND METHODS

A prospective cohort study was conducted from October 2017 to April 2019 in seven Brazilian hospitals. Data from 447 adult patients with NGT/NET were collected through electronic forms. Three methods were used to assess the NGT/NET-related adverse events: (1) encouraging spontaneous reports; (2) regular visits to the wards; and (3) review of medical records. The events were classified as mechanical device-related complications and other events. The degree of harm was classified according to the World Health Organization's International Classification for Patient Safety. Data were analyzed using the R program, version 3.5.3. The following tests were applied to identify associations between the explanatory and response variables: Cochran-Armitage Chi-Square test, Fisher's exact test, and Linear-by-linear Chi-Square test. Logistic regression analysis was performed to verify the predictors of mechanical device-related complications. All analyses were performed considering a 5% significance level.

RESULTS

191 NGT/NET-related adverse events were identified in 116 patients; the majority were mechanical device-related complications and resulted in mild harm to the patient. At the moment of the event, patients had a mean of 3.27 comorbidities, were highly dependent on nursing care, with high risk of death and altered level of consciousness. There was no association between the degree of harm and the care complexity, disease severity or level of consciousness. Intensive care was the strongest predictor for mechanical device-related complications and critical patients had a four times greater likelihood of presenting this type of event when compared to patients receiving minimal care.

CONCLUSION

Intensive care patients should receive special attention as the complexity of care is an important predictor for mechanical device-related complications in tube fed patients.