An analysis of two incidents of medicine administration to a patient with dysphagia

Kelly, Jennifer; Eggleton, Alison; Wright, David

doi:10.1111/j.1365-2702.2010.03457.x

Cited by 15 publications

(12 citation statements)

References 45 publications

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“…However, it can be a significant problem for those patients who require their medicines at specific times, for example, those on anti‐Parkinson drugs. Several of the patients in this study did have Parkinson’s disease and one of them forms the focus of a critical incident analysis (Kelly et al. 2011).…”

Section: Discussionmentioning

confidence: 99%

Medicine administration errors and their severity in secondary care older persons’ ward: a multi‐centre observational study

Kelly

Wright

2011

Journal of Clinical Nursing

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Section: Discussionmentioning

confidence: 99%

Medicine administration errors and their severity in secondary care older persons’ ward: a multi‐centre observational study

Kelly

Wright

2011

Journal of Clinical Nursing

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“…pharmacokinetic and pharmacodynamic changes (Mc Gillicuddy et al, 2015;Stegemann et al, 2010;Stegemann et al, 2012). Other studies have found that modifications may also arise due to the culture within the institution including prescribing, dispensing and administration practices and communication and multi-disciplinary team engagement (Bourdenet et al, 2015;Hanssens et al, 2006;Kelly et al, 2011a). Alternatives to ODF modification recommended in the best practice guidelines include unlicensed formulations or alternative medicines (Wright et al, 2006).…”

Section: Discussionmentioning

confidence: 95%

Modification of oral dosage forms for the older adult: An Irish prevalence study

Gillicuddy

Kelly

Sweeney

et al. 2016

International Journal of Pharmaceutics

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“…This was because the prescribed formulations were not designed for patients with dysphagia, for administration via an enteral tube or because the nurse did not have the information at hand to make an informed choice as to what the best option would be. These beliefs were reinforced when the same patient was observed receiving the same medicines by two different nurses and received them entirely differently [32]. One recommendation resulting from the large number of errors seen at the point of medicines administration to patients with dysphagia was that nurses should be regularly observed to identify and address any learning needs [33].…”

Section: Medication Errorsmentioning

confidence: 99%

Optimising Medicines Administration for Patients with Dysphagia in Hospital: Medical or Nursing Responsibility?

2020

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Dysphagia is common—not only associated with stroke, dementia, Parkinson’s but also in many non-neurological medical problems—and is increasingly prevalent in ageing patients, where malnutrition is common and pneumonia is frequently the main cause of death. To improve the care of people with dysphagia (PWD) and minimise risk of aspiration and choking, the textures of food and drinks are frequently modified. Whilst medicines are usually concurrently prescribed for PWD, their texture is frequently not considered and therefore any minimisation of risk with respect to food and drink may be being negated when such medicines are administered. Furthermore, evidence is starting to emerge that mixing thickeners with medicines can, in certain circumstances, significantly affect drug bioavailability and therefore amending the texture of a medicine may not be straightforward. Research across a number of hospital trusts demonstrated that PWD are three times more likely to experience medication administration errors than those without dysphagia located on the same ward. Errors more commonly seen in PWD were missed doses, wrong formulation and wrong preparation through medicines alteration. Researchers also found that the same patient with dysphagia would be given their medicines in entirely different ways depending on the person administering the medicine. The alteration of medicines prior to administration has potential for patient harm, particularly if the medicine has been designed to release medicines at a pre-defined rate or within a pre-defined location. Alteration of medicines can have significant legal implications and these are frequently overlooked. Dispersing, crushing or mixing medicines can be part of, or misconstrued as, covert administration, thus introducing a further raft of legislation. Guidance within the UK recommends that following identification of dysphagia, the ongoing need for the medicine should be considered, as should the most appropriate route and formulation, with medicines alteration used as a last resort. The patient should be at the centre of any decision making. Evidence suggests that in the UK this guidance is not being followed. This article considers the clinical and legal issues surrounding administration of medicines to PWD from a UK perspective and debates whether medicines optimisation should be the primary responsibility of the prescriber when initiating therapy on the ward or the nurse who administers the medicine.

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An analysis of two incidents of medicine administration to a patient with dysphagia

Cited by 15 publications

References 45 publications

Medicine administration errors and their severity in secondary care older persons’ ward: a multi‐centre observational study

Medicine administration errors and their severity in secondary care older persons’ ward: a multi‐centre observational study

Modification of oral dosage forms for the older adult: An Irish prevalence study

Optimising Medicines Administration for Patients with Dysphagia in Hospital: Medical or Nursing Responsibility?

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