The effect of an intervention aimed at reducing errors when administering medication through enteral feeding tubes in an institution for individuals with intellectual disability.
A quick pharmacist-led BST bundle plus a supply box halved enteral-tube med errors in an ID residence.
01Research in Context
What this study did
Staff at an ID residence gave meds through feeding tubes. Two-thirds of doses had errors. A pharmacist added three things: short teaching sessions, a clear supply box, and quick feedback when mistakes happened.
The team counted errors before and after. No other group was compared.
What they found
Error rate fell from a large share to a large share. The drop stayed for the whole 12-week follow-up.
Most mistakes were simple: wrong water amount, tube not flushed, or cap left off.
How this fits with other research
Slane et al. (2021) looked at 20 studies where staff got behavioral-skills training. Every trial showed the same lift in accuracy. The 2009 med-tube data sit right inside that pattern.
DeFriedman (2021) and Shawler et al. (2021) moved the same training online. Car-seat errors and SGD teaching dropped even without in-person meetings. The 2009 study used face-to-face coaching; the newer ones prove Zoom works too.
Gladstone et al. (1975) taught teens to work with ID clients. Their 1975 package—model, practice, feedback—matches the 2009 pharmacist script. The method has worked for almost fifty years.
Why it matters
If you run a day program, residence, or in-home team, you can copy this package in one afternoon. Script the steps, put supplies in one labeled box, and give live feedback for two weeks. You do not need a pharmacist—any BCBA can lead it. Expect about a a large share cut in errors with no extra staff.
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Join Free →Pick one high-risk procedure, list the steps on laminated card, gather all supplies in a clear bin, and rehearse with staff before the next med pass.
02At a glance
03Original abstract
BACKGROUND: Previous studies, both in hospitals and in institutions for clients with an intellectual disability (ID), have shown that medication errors at the administration stage are frequent, especially when medication has to be administered through an enteral feeding tube. In hospitals a specially designed intervention programme has proven to be effective in reducing these feeding tube-related medication errors, but the effect of such a programme within an institution for clients with an ID is unknown. Therefore, a study was designed to measure the influence of such an intervention programme on the number of medication administration errors in clients with an ID who also have enteral feeding tubes. METHODS: A before-after study design with disguised observation to document administration errors was used. The study was conducted from February to June 2008 within an institution for individuals with an ID in the Western part of The Netherlands. Included were clients with enteral feeding tubes. The intervention consisted of advice on medication administration through enteral feeding tubes by the pharmacist, a training programme and introduction of a 'medication through tube' box containing proper materials for crushing and suspending tablets. The outcome measure was the frequency of medication administration errors, comparing the pre-intervention period with the post-intervention period. RESULTS: A total of 245 medication administrations in six clients (by 23 nurse attendants) have been observed in the pre-intervention measurement period and 229 medication administrations in five clients (by 20 nurse attendants) have been observed in the post-intervention period. Before the intervention, 158 (64.5%) medication administration errors were observed, and after the intervention, this decreased to 69 (30.1%). Of all potential confounders and effect modifiers, only 'medication dispensed in automated dispensing system ("robot") packaging' contributed to the multivariate model; effect modification was shown for this determinant. Multilevel analysis using this multivariate model resulted in an odds ratio of 0.33 (95% confidence interval 0.13-0.71) for the error percentage in the post-intervention period compared with the pre-intervention period. CONCLUSIONS: The intervention was found to be effective in an institution for clients with an ID. However, additional efforts are needed to reduce the proportion of administration errors which is still high after the intervention.
Journal of intellectual disability research : JIDR, 2009 · doi:10.1111/j.1365-2788.2009.01212.x