CDSS assisted pharmacy intervention reduces feeding tube-related medication errors in hospitalized patients: a focus on medication suitable for feeding tube administration.

BACKGROUND: Administering medication through an enteral feeding tube is a frequent cause of errors resulting in increased morbidity and cost. Studies on interventions to prevent these errors in hospitalized patients, however, are limited. OBJECTIVE: To study the effect of a clinical decision support system (CDSS) assisted pharmacy intervention on the incidence of feeding tube-related medication errors (FTRMEs) in hospitalized patients. METHODS: A pre-post intervention study was conducted between October 2014 and May 2015 in the Catharina Hospital, the Netherlands. Patients admitted to the wards of bowel and liver disease, oncology, or neurology, using oral medication and had an enteral feeding tube were included. Pre-intervention patients were given care as usual. The intervention consisted of implementing a CDSS assisted pharmacy check while also implementing standard operating procedures and educating personnel. A FTRME was defined as the administration of inappropriate medication through an enteral feeding tube. The incidence was expressed as the number of FTRME per medication administration. Multivariate Poisson regression was used to calculate the incidence ratio (IR) comparing both phases. RESULTS: Eighty-one patients were included, 38 during pre-intervention and 43 during intervention phase. Incidence of FTRMEs in the pre-intervention phase was 0.15 (95% confidence interval (CI) 0.07-0.23) versus 0.02 (CI 0.00-0.04) in the intervention phase, resulting in an adjusted IR of 0.13 (CI 0.10-0.18). DISCUSSION: Incidence of FTRMEs as well as the IR are comparable to previous studies. CONCLUSION: The intervention resulted in a substantial reduction in the incidence of feeding tube-related medication errors. This article is protected by copyright. All rights reserved.