Appropriateness of administration of nasogastric medication and preliminary intervention

Bifari I, Ahmed Alharbi Y. Unraveling medication errors in enteral tube administration: A cross-sectional study in geriatric patients receiving home health care

Background

Medication administration through enteral feeding tubes requires careful consideration, as several medications are unsuitable for such administration due to interactions with feeding formulas or adverse effects when crushed. These errors can lead to feeding tube obstruction, reduced drug efficacy, or drug toxicity.

Objective

This study aimed to assess medication errors in geriatric patients using enteral feeding tubes who were enrolled in a home health care program.

Method

This was a cross-sectional observational study conducted at the Ministry of Health Government Hospital in Makkah City, Saudi Arabia. Medication errors related to chronic oral drugs in geriatric patients using enteral feeding tubes were evaluated, including inappropriate medications for enteral tube administration, inappropriate preparation, drug-nutrient interaction, and availability of liquid formulation, following established guidelines.

Results

Of the total 233 medications prescribed to 46 patients receiving enteral tube feeding at home, 49.3% exhibited at least one form of medication error, totaling 135 errors. Medication errors were highly prevalent among the patients (93.4%), with the leading cause being the administration of medications unsuitable for enteral feeding tubes (33.3%), predominantly due to the use of controlled release or enteric-coated formulations.

Conclusion

This study underscores the high prevalence of medication errors in older patients receiving enteral feeding at home. To ensure patient safety and optimal outcomes, healthcare professionals should utilize available resources and seek expert advice when selecting medications and dosage forms for tube-fed patients. Pharmacists play a critical role in promoting safe drug use and can greatly contribute by educating patient caregivers on proper medication preparation and administration techniques, thus preventing harm to patients.

Assessment of Good Practice Guidelines for Administration of Drugs via Feeding Tubes by a Clinical Pharmacist in the Intensive Care Unit

Background

In intensive care units, patients are frequently unable to take oral drugs because of orotracheal intubation or sedation.

Local Problem

Adverse events occurred during the administration of drugs by feeding tube. This study assessed the impact of implementing good practice guidelines by a clinical pharmacist on the prescription and administration of drugs through feeding tubes.

Methods

Nonconformity of drug prescription and administration in patients with feeding tubes was assessed before and after implementation of good practice guidelines in the intensive care unit of a large teaching hospital. Data were collected from medical records and interviews with physicians and nurses using a standardized form. Assessment of prescription nonconformity included compatibility of a drug’s absorption site with the administration route. Assessment of administration nonconformity included the preparation method.

Results

The analysis included 288 prescriptions and 80 administrations before implementation and 385 prescriptions and 211 administrations after implementation. Prescriptions in which the drug’s absorption site was not compatible with the administration route decreased significantly after implementation (19.8% vs 7.5%, P < .01). Administration nonconformity decreased significantly in regard to crushing tablets and opening capsules (51.2% vs 4.3%, P < .01) and the solvent used (67.1% vs 3.5%, P < .01). Simultaneous mixing of drugs in the same syringe did not decrease significantly (71.2% vs 62.9%, P = .17).

Conclusion

Implementation of good practice guidelines by a multidisciplinary team in the intensive care unit significantly improved practices for administering crushed, opened, and dissolved oral forms of drugs by feeding tube.

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.

Recommendations for crushing Circadin® (melatonin) tablets for safe and reliable delivery via pediatric nasogastric tubes

Melatonin is an important drug in pediatric medicine which often requires delivery through a narrow bore nasogastric tube (e.g. FR6; 1300 µm internal diameter) for patients that cannot swallow tablets. Although Circadin® 2 mg tablets are often crushed for nasogastric delivery, there is an absence of evidence for the effectiveness of different methods for producing powders that can be administered without risk of blocking nasogastric tubes. Our aim was to develop a robust protocol for crushing Circadin tablets and suspending the powder for safe administration via paediatric nasogastric tubes. Circadin tablets were crushed using four different tablet crushers. For comparison, a pestle and mortar and tablespoon were also used to crush tablets as these techniques are also used in clinical practice. The particle size of powders resulting from different crushing maneuvers was evaluated using sieve analysis, laser diffraction and image-based sizing methods. For all the tablet crushers, five operations produced powders with irregular-shaped individual particles less than 500 µm diameter. A protocol termed 'King's 5-5-5' was developed for tablet crushers: powder obtained after 5 crushes was suspended in 5 mL water and delivered through NG tubes with pre and post-administration flushing with 5 mL water. This protocol is simple, low cost, uses readily available materials and enables the safe and reliable delivery of melatonin to paediatric patients without the fear of blocking nasogastric tubes.

Safe medication management and use of narcotics in a Joint Commission International-accredited academic medical center hospital in the People's Republic of China

Safe medication management and use of high-alert narcotics should arouse concern. Risk management experiences in this respect in a large-scale Joint Commission International (JCI)-accredited academic medical center hospital in the People’s Republic of China during 2011–2015, focusing on organizational, educational, motivational, and information technological measures in storage, prescribing, preparing, dispensing, administration, and monitoring of medication are summarized. The intensity of use of meperidine in hospitalized patients in 2015 was one-fourth that in 2011. A 100% implementation rate of standard storage of narcotics has been achieved in the hospital since December 2012. A “Plan, Do, Check, Act” cycle was efficient because the ratio of number of inappropriate narcotics prescriptions to total number of narcotics prescriptions for inpatients decreased from August 2014 to December 2014 (28.22% versus 2.96%, P=0.0000), and it was controlled below 6% from then on. During the journey to good pain management ward accreditation by the Ministry of Health, People’s Republic of China, (April 2012–October 2012), the medical oncology ward successfully demonstrated an increase in the pain screening rate at admission from 43.5% to 100%, cancer pain control rate from 85% to 96%, and degree of satisfaction toward pain nursing from 95.4% to 100% (all P-values <0.05). Oral morphine equivalent dosage in the good pain management ward increased from 2.3 mg/patient before June 2012 to 54.74 mg/patient in 2014. From 2011 to 2015, the oral morphine equivalent dose per discharged patient increased from 8.52 mg/person to 20.36 mg/person. A 100% implementation rate of independent double-check prior to narcotics dosing has been achieved since January 2013. From 2014 to 2015, the ratio of number of narcotics-related medication errors to number of discharged patients significantly decreased (6.95% versus 0.99%, P=0.0000). Taken together, continuous quality improvements have been achieved in safe medication management and use of narcotics by an integrated multidisciplinary collaboration during the journey to JCI accreditation and in the post-JCI accreditation era.

Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era

Background

Medication errors may occur during prescribing, transcribing, prescription auditing, preparing, dispensing, administration, and monitoring. Medication administration errors (MAEs) are those that actually reach patients and remain a threat to patient safety. The Joint Commission International (JCI) advocates medication error prevention, but experience in reducing MAEs during the period of before and after JCI accreditation has not been reported.

Methods

An intervention study, aimed at reducing MAEs in hospitalized patients, was performed in the Second Affiliated Hospital of Zhejiang University, Hangzhou, People’s Republic of China, during the journey to JCI accreditation and in the post-JCI accreditation era (first half-year of 2011 to first half-year of 2014). Comprehensive interventions included organizational, information technology, educational, and process optimization-based measures. Data mining was performed on MAEs derived from a compulsory electronic reporting system.

Results

The number of MAEs continuously decreased from 143 (first half-year of 2012) to 64 (first half-year of 2014), with a decrease in occurrence rate by 60.9% (0.338% versus 0.132%, P<0.05). The number of MAEs related to high-alert medications decreased from 32 (the second half-year of 2011) to 16 (the first half-year of 2014), with a decrease in occurrence rate by 57.9% (0.0787% versus 0.0331%, P<0.05). Omission was the top type of MAE during the first half-year of 2011 to the first half-year of 2014, with a decrease by 50% (40 cases versus 20 cases). Intravenous administration error was the top type of error regarding administration route, but it continuously decreased from 64 (first half-year of 2012) to 27 (first half-year of 2014). More experienced registered nurses made fewer medication errors. The number of MAEs in surgical wards was twice that in medicinal wards. Compared with non-intensive care units, the intensive care units exhibited higher occurrence rates of MAEs (1.81% versus 0.24%, P<0.001).

Conclusion

A 3-and-a-half-year intervention program on MAEs was confirmed to be effective. MAEs made by nursing staff can be reduced, but cannot be eliminated. The depth, breadth, and efficiency of multidiscipline collaboration among physicians, pharmacists, nurses, information engineers, and hospital administrators are pivotal to safety in medication administration. JCI accreditation may help health systems enhance the awareness and ability to prevent MAEs and achieve successful quality improvements.