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

Abstract

Background: Patients with nasogastric/nasoenteric tube (NGT/NET) are at increased risk of adverse outcomes due to errors occurring during oral medication preparation and administration.

Aim: To implement a quality improvement programme to reduce the proportion of errors in oral medication preparation and administration through NGT/NET in adult patients.

Methods: An observational study was carried out, comparing outcome measures before and after implementation of the integrated quality programme to improve oral medication preparation and administration through NGT/NET. A collaborative approach based on Plan-Do-Study-Act (PDSA) cycle was used and feedback was given during multidisciplinary meetings.

Interventions: Good practice guidance for oral medication preparation and administration through NGT/NET was developed and implemented at the hospital sites; nurses were given formal training to use the good practice guidance; a printed list of oral medications that should never be crushed was provided to all members of the multidisciplinary team, and a printed table containing therapeutic alternatives for drugs that should never be crushed was provided to prescribers at the prescribing room.

Results: Improvement was observed in the following measures: crushing enteric-coated tablets and mixing drugs during medication preparation (from 54.9% in phase I to 26.2% in phase II; p 0.0010) and triturating pharmaceutical form of modified action or dragee (from 32.8 in phase I to 19.7 in phase II; p 0.0010). Worsening was observed though in the following measures: crush compressed to a fine and homogeneous powder (from 7.4%% in phase I to 95% phase II; p 0.0010) and feeding tube obstruction (from 41.8% in phase I to 52.5% phase II; p 0.0950).

Conclusion: Our results highlight how a collaborative quality improvement approach based on PDSA cycles can meet the challenge of reducing the proportion of errors in oral medication preparation and administration through NGT/NET in adult patients. Some changes may lead to unintended consequences though. Thus, continuous monitoring for these consequences will help caregivers to prevent poor patient outcomes.

Keywords: PDSA; medication safety; quality improvement.

Figure 1

Quality improvement program phase II diagram. Cycles 1 and 2: two consecutive cycles were performed. The first served to elaborate the good practice guide for the preparation and administration of oral medication via NGT/ NET. The second was to offer training to the nursing staff. Cycle 3: the goal was to evaluate drug preparation and administration via NGT/ NET and compare the data with the baseline result. NGT/NET, nasogastric/nasoenteric tube; PDSA, Plan-Do-Study-Act.

Figure 2

Weekly statistical process control chart showing the percentage of crush compressed to a fine and homogeneous powder. Control chart showing the percentage of crush compressed to a fine and homogeneous powder. Administered to 16 patients reporting continuous observation and follow-up periods. Hospital elected to the improvement programme made changes to improve oral medication preparation and administration techniques via NGT/ NET. PDSA 3: We found that in the hospital there was no pestle mortar to crush the solid forms, it is clear that the process worsened. NGT/NET, nasogastric/nasoenteric tube; PDSA, Plan-Do-Study-Act.