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In certain situations the ability to eat or take medications by mouth may be compromised. Enteral tubes are life-saving tools to assist with nutrition and medication administration. However, not all medications are safe to be administered by enteral tube.

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Improved Safety of Enteral Tube Medication Administration

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Administering medications through an enteral tube (ET) is a frequent cause of errors, resulting in increased morbidity and costs. By leveraging technology within the patient record system and utilizing medication use experts, our innovation enhances the safety of medication administration via enteral tube.

This innovation is emerging and worth watching as it is being assessed in early implementations. See more emerging innovations.

Adoptions:

1 successful

Awards and Recognition:

VHA Shark Tank Finalist

In certain situations the ability to eat or take medications by mouth may be compromised. Enteral tubes are life-saving tools to assist with nutrition and medication administration. However, not all medications are safe to be administered by enteral tube.

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High Reliability Information Technology Nursing Outpatient Care Pharmacy Primary Care
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Overview

Problem

The Institute for Safe Medication Practices (ISMP) recognizes medication administration through enteral tubes (ET) as a frequent cause of errors, resulting in occluded tubes, altered clinical response, increased healthcare costs, and adverse effects. ISMP recommends every organization develop methods for ensuring safe administration of medications through ET ... See more

Images

Not all medications are compatible for enteral tube medication administration.

Not all medications are compatible for enteral tube medication administration. Don't be in a rush to crush, know before you tube!

Solution

The purpose of our project was to improve the safety of medication administration via ET by the addition of a CPRS Clinical Reminder Order Check (CROC) and a comprehensive medication review by a pharmacist. The CROC alerts healthcare staff to the ET medication needs of the Veteran and allows for the prospective review of all new medication orders. In conjunc ... See more

Results

In one year, 41 e-consults were completed and 41 CROC alerts added. Among the 41 e-consults there were 41 inappropriate orders for enteral tube (ET) medication administration. "Inappropriate" was defined as medications without existing data for ET administration AND present on the ISMP "Do Not Crush" list. Medications with existing data to suggest that ET ad ... See more

Images

The pictures shows a bar graph. At baseline among 41 veterans with enteral tubes, there were 41 medications that were not compatible with enteral tube administration. Using the med alert and med review, these errors were reduced to just 6 in one year, an 85.4% reduction in medication errors. These avoided med errors are equivalent to a cost avoidance of $37,485.

At baseline among 41 veterans with enteral tubes, there were 41 medications that were not compatible with enteral tube administration. Using the med alert and med review, these errors were reduced to just 6 in one year, an 85.4% reduction in medication errors. These avoided med errors are equivalent to a cost avoidance of $37,485.

Metrics

  • 41 e-consults completed with CROC alert added, enhancing enteral tube safety for 41 unique veterans.
  • Inappropriate enteral tube medication orders reduced by 85.4%.
  • 35 potential medication errors were avoided. One study found that the cost of a primary ET complication was $1071. Extrapolating, we estimate a cost avoidance of $37,485 by preventing the 35 inappropriate medications from reaching Veterans. If this is implemented at all VAs, the number of error reductions and cost savings could increase exponentially.
  • Staff that utilized the e-consult and CROC were surveyed and 100% of those surveyed had improved experiences and perceptions of safety when prescribing or processing ET medication orders.

Diffusion tracker

Does not include Clinical Resource Hubs (CRH)

Statuses

MO: Kansas City VA Medical Center (Kansas City, Missouri)

There are no in-progress adoptions for this innovation.

There are no unsuccessful adoptions for this innovation.

Multimedia

Videos

How to Take Medicines Via an Enteral Feeding Tube - English

Como Ingerir Medicamentos por Meedio de una Sonda Nasogastrica

Implementation

Timeline

  • Week 1
    Medication use evaluation: retrospective assessment of medication errors among outpatients within the healthcare system currently utilizing ET for medication administration. Data pull may take 4-8 hours to develop comprehensive list of veterans to use for baseline data and to identify veterans that would benefit from addition of the CROC and e-consult. Each veteran chart is then reviewed (10-20 minutes per chart) to assess for inappropriate ET medications. These results would serve both as baseline data and identification of target population.
  • Week 2-4
    Education: Work with facility leaders to identify a project champion and pharmacy staff to complete the e-consult. Distribute education for the ET safety feature to all clinical staff. Support any educational needs for pharmacists completing enteral tube e-consults.
  • Week 3
    CROC Development: work with local CACs to add the CROC. When the CROC is added for Veterans requiring ET medication administration, it will trigger an alert in CPRS to prescribers ordering oral meds and also alerts pharmacists in VISTA processing orders. This creates a safety net by alerting the prescriber and pharmacist to prospectively review the medication for ET administration.
  • Week 3
    Upload e-consult, note Templates: Work with CACs to have pharmacist e-consult, note template, and ET order sets added to CPRS.
  • Week 4-8
    Implement the CROC and e-consult safety features. Complete e-consults for veterans identified with ET from the MUE data pull. Re-assess the MUE to determine if inappropriate medications have been addressed and resolved. Refine processes as needed and provide ongoing education.

Departments

  • Gastroenterology
  • Pharmacy
  • Geriatrics
  • Administration
  • Information technology
  • Primary care
  • Nutrition, food, and dietary

Core Resources

Resource type Resource description
PEOPLE
  • Clinical Application Coordinator required for 1 day for initial set up, then approximately 4 hours per year for annual CROC maintenance/review.
  • Pharmacist: Estimated FTE of 0.02-0.1 per year for completion of e-consults. FTE varies based on the number of Veterans with ET identified at each facility. Depending on facility resources, completion of the ET e-consults could be completed by outpatient pharmacy, the veteran’s PACT pharmacist, or designated to a specific clinical pharmacist (such as geriatric, HBPC, or GI pharmacist).
PROCESSES
  • Training: Support the educational needs of pharmacists completing ET e-consults.
  • Education: Provide clinical staff (providers, nurses, pharmacists, etc) with education about the CROC and e-consult safety features.
TOOLS
  • CPRS
  • VA National Library for ET medication administration resources

Optional Resources

Files

Support Resources

Links

Risks and mitigations

Risk Mitigation
Alert Fatigue: The CROC does create an additional alert to notify the provider and pharmacist of the Veteran's use of ET for medications. Not knowing the patient requires ET for medication administration could be a greater risk, and without the CROC there is no current method within CPRS to identify Veterans with ETs. Thorough and consistent staff education will mitigate this risk.
Manual CROC initiation: CROC requires manual activation or de-activation by VA staff. To facilitate addition of the CROC, any staff can activate CROC, making it universally accessible. The CROC also does not expire and remains active until intentionally discontinued.
Staff awareness VA staff must be fully educated to ensure proper utilization of the pharmacist e-consult and CROC safety features.
Lack of ET knowledge: potential lack of GI or ET knowledge among pharmacy staff. The VA National Library has excellent resources available to all VA pharmacists to assist with safety and efficacy medication evaluations. TMS also has continuing education trainings specific to enteral tube medication administration and safety.

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About

Origin story

According the Academy of Managed Care Pharmacy (AMCP), "medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries in hospitals alone are at least $3.5 billion a year." Patients requiring enteral tubes (ET) for medication administration may be even mor ... According the Academy of Managed Care Pharmacy (AMCP), "medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries in hospitals alone are at least $3.5 billion a year." Patients requiring enteral tubes (ET) for medication administration may be even more vulnerable to errors due the complexity of this route of administration. The need for enhanced safety for ET patients was first recognized at our facility when a Veteran requiring ET administration for medications was prescribed diltiazem CD. The provider, in thinking he was improving the patient experience by converting him from diltiazem IR dosed three times a day to once daily Diltiazem CD was either not aware of the Veteran's ET care needs or not aware that Diltiazem CD is identified on the ISMP do not crush list and if crushed and if administered by ET could cause a precipitous drop in blood pressure and heart rate. Fortunately, the medication error was identified by an HBPC pharmacist familiar with the Veteran’s care needs before the medication reached the Veteran. This incident highlighted the lack of a standard method within CPRS to identify that the Veteran requires ET administration. There was no immediate solution to this technologic deficit but working as a team of pharmacists and CACs the CROC was ultimately developed to provide an alert within CPRS. The e-consult was introduced to relieve workload off primary care providers and provide medication assessments by subject matter experts. With the safety features developed, there are now multiple check points to prevent ET medication errors. Not only does this standardized process provide strides towards zero harm and reduced medication errors, it also provides unlimited cost savings opportunities through prevention of ET medication errors.

Original team

Elizabeth Eickman

HBPC Clinical Pharmacy Provider

Paige Zicarelli

PACT Clinical Pharmacy Provider

Kathryn Pinkham

GI Clinical Pharmacy Specialist

Kyleigh Gould

Associate Chief of Clinical Pharmacy

Micheal Rogers

VISN 15 CAC

Thelma Agustin

GI Care Coordinator

Joan Thalken

Program Analyst

Search tags

High Reliability Information Technology Nursing Outpatient Care Pharmacy Primary Care