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Improved Safety of Enteral Tube Medication Administration
Share PrintAdministering 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.
Origin:
May 2021, Kansas City VA Medical Center (Kansas City, Missouri)
Adoptions:
1 successful
Awards and Recognition:
VHA Shark Tank Finalist
Recent Updates
Overview
Problem
Images
Links
- ISMP identifies frequent errors with ET medication administration and outlines safe practice recommendations. Preventing Errors when Administering Drugs Via an Enteral Feeding Tube
Solution
- Powerpoint providing staff education for the CPRS CROC and pharmacy e-consult Enteral Tube Medication Safety Feature
Files
Results
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)
Implementation
Timeline
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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
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Risks and mitigations
Risk | Mitigation |
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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. |
About
Origin story
Original team
Elizabeth Eickman
HBPC Clinical Pharmacy Provider
Paige Zicarelli
PACT Clinical Pharmacy Provider
Kathryn Rau
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
Comment
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