2025 Southeastern Residency Conference

Title: A Retrospective Evaluation of an Electronic Medical Record Alert to Pharmacists on the Incidence of Inappropriate Medication Administration in Patients with Feeding Tubes 

Authors: Devin O'Brien, Rosemary Garbowski, Matthew Lane, Saumil Vaghela

Background: Medication administration is an important part of the foundation for medication safety and efficacy. Various studies have demonstrated the frequency of inappropriate administration of medications through a feeding tube. Many of these studies have shown that pharmacist interventions can positively impact the percentage of medications administered appropriately in patients with feeding tubes. Few studies have evaluated the effectiveness of a pharmacist-directed alert on the appropriate administration of medications. The purpose of this study was to evaluate the effectiveness of an electronic medical record alert to pharmacists on the incidence of inappropriate medication administration in patients with feeding tubes.  

Methods: A retrospective chart review was conducted using the electronic medical record (EMR) at an acute care community hospital. Chart reviews were conducted on patients with tube feeding (TF) orders who were admitted prior to and following implementation of the EMR alert. The pre-implementation period was between June 1, 2024 and August 31, 2024. The post-implementation period was between October 1, 2024 and December 31, 2024. A wash-out period was designated between September 1, 2024 and September 30, 2024 to ensure that all patients with a TF order triggered the alert to pharmacists in the EMR. Patients were included if they had a TF order placed and had at least one scheduled medication ordered to be administered enterally. Patients were excluded if they were covered by a service that participated in daily multidisciplinary team rounding, as the medications for these patients were individually evaluated regardless of the pharmacist-directed alert. The primary outcome for this study was the composite incidence of inappropriate medication administration and medication administration omissions in patients with feeding tubes (for example: crushed medications that should not be crushed per the package insert or a liquid administered through the feeding tube that has potential for binding to the feeding tube). The secondary outcome for this study was inappropriate administration of high risk medications. All data points collected for each patient were compiled in an electronic spreadsheet. 

Results: A total of 52 patients were included in the study, 29 in the pre-implementation group and 23 in the post-implementation group. For the primary endpoint of composite incidence of inappropriate medication administration and medication administration omissions,122 errors were found in the pre-implementation group and 71 in the post-implementation group. For the secondary outcome of inappropriate administration of high risk medications, there were zero patients in both groups. 

Conclusion: An EMR alert to pharmacists to evaluate medications in patients with feeding tubes may help to decrease the number of inappropriate medication administrations