A Scoping Review of Interventions to Reduce Feeding Tube-Related Medication Errors

Medication errors remain problematic when using feeding tubes for enteral nutrition and pharmacotherapy. Adverse effects, reduced medication efficacy, and toxicity are reported despite best practice guidelines. This scoping review explores interventions to reduce feeding tube-related medication errors. Thirteen trials investigated error reduction or improvements in medication preparation and administration. Eight interventions were identified: pharmacist interventions, pharmacist attending rounds, addition of standard operating procedures, pharmacist-provided education, medication information, creation of medication error reporting systems, decision flow charts, and clinical decision support systems. The results were mixed. Some studies reported high acceptance rates of pharmacist recommendations, while others did not. The rates of error reduction varied (30.8%-85.2%) and we found decreased need for dosage modification or feeding tube-related medication error due to improvements in knowledge and practice after education. Only one study reported an increase in tube occlusion due to failure to pulverize medications. Most studies were small, lacked blinding or controls, and performed measurements immediately post-intervention. There is a need for additional research.