Effect of an intervention aimed at reducing errors when administering medication through enteral feeding tubes in an institution for clients with mental retardation [Effect van interventie ter vermindering van fouten bij medicatie-toediening via voedingssondes in een intramurale voorziening voor mensen met een verstandelijke beperking]

作者：Idzinga J C; Van Den Bemt P M L A^*; De Jong A L

来源：Pharmaceutisch Weekblad, 2009, 144(25): 108-112.

Objective: To measure the influence of an intervention programme on the number of medication administration errors in an institution for clients with mental retardation with enteral feeding tubes (who received both feeding and medication through these tubes). In hospitals such a specially designed intervention programme has proven to be effective in reducing feeding tube-related medication errors. Design: A before-after study design was used with disguised observation to document administration errors. Methods: Included were clients with enteral feeding tubes from an institution for clients with mental retardation. Administration errors were measured during three weeks before implementation of the intervention and during three weeks thereafter. The intervention consisted of a combination of pharmacist advice and education sessions for the personnel involved in administering medication. Implementation of the intervention lasted three weeks. During this training period the education sessions took place and a start was made with pharmacist advice. Results: Before the intervention 158 errors in 245 observations (6 clients) were measured. After the intervention 69 errors in 229 observations (the same clients with the exception of one client who had died) were measured. The intervention thus resulted in a statistically significant reduction of the proportion of administration errors from 64% to 30% (relative risk 0.47; 95% confidence interval 0.38-0.58). Conclusion: The intervention was found to be effective in an institution for clients with mental retardation. However, additional efforts are needed to reduce the proportion of administration errors which can still be considered relatively high after the intervention.