Safe medication swallowing in Dysphagia: a collaborative improvement project

Area of Science:

• Gerontology
• Patient Safety
• Health Informatics

Background:

• Medication administration to patients with dysphagia presents significant safety risks, including choking.
• Existing communication systems often contain discrepancies regarding medication swallowing recommendations.
• Inappropriate drug administration can occur due to fragmented information.

Purpose of the Study:

• To identify system problems contributing to inappropriate medication administration in patients with dysphagia.
• To implement and evaluate practice changes aimed at improving communication of swallowing recommendations.
• To enhance patient safety by preventing medication errors in this vulnerable population.

Main Methods:

• A chart audit and caregiver interviews were conducted with 60 elderly patients.
• Nursing medication administration methods were compared against various communication tools (MAR, diet orders, SLP recommendations, care plans).
• Intervention involved standardized language, doctor's orders, MAR inclusion, and a pharmacy alert system, followed by pre- and post-implementation audits.

Main Results:

• Significant discrepancies were found between nursing actions and documented swallowing recommendations.
• Post-implementation audits demonstrated high compliance with the new practice changes.
• The intervention successfully improved adherence to speech-language pathologist (SLP) medication-related swallowing recommendations.

Conclusions:

• Changes to interprofessional communication processes for medication swallowing recommendations enhance patient safety.
• Standardized protocols and integrated alerts are effective in preventing medication errors in dysphagia patients.
• Improved communication prevents inadvertent prescribing, dispensing, or crushing of medications for patients with dysphagia.