Journal of Research in Pharmacy Practice

Errors of oral medication administration in a patient with enteral feeding tube

Authors

. Shahram Emami 1
. Hadi Hamishehkar 2
. Ata Mahmoodpoor 3
. Simin Mashayekhi 4
. Parina Asgharian 1

1 Student’s Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran

2 Applied Drug Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Department of Clinical Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran

3 Department of Anesthesiology and Critical Care Medicine, Tabriz University of Medical Sciences, Tabriz, Iran

4 Department of Clinical Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran National Public Management Centre, Tabriz University of Medical Sciences, Tabriz, Iran

Abstract
Enteral feeding tube is employed for feeding of critically ill patients who are unable to eat. 
In the cases of oral medication administration to enterally fed patients, some potential 
errors could happen. We report a 53-year-old man who was admitted to intensive care 
unit (ICU) of a teaching hospital due to the post-CPR hypoxemic encephalopathy. The 
patient was intubated and underwent mechanical ventilation. A nasogastric (NG) tube 
was used as the enteral route for nutrition and administration of oral medications. Oral 
medications were crushed then dissolved in tap water and were given to the patient 
through NG tube. In present article we report several medication errors occurred during 
enterally drug administration, including errors in dosage form selection, methods of oral 
medication administration and drug interactions and incompatibility with nutrition formula. 
These errors could reduce the effects of drugs and lead to unsuccessful treatment of 
patient and also could increase the risk of potential adverse drug reactions. Potential 
leading causes of these errors include lack of drug knowledge among physicians, inadequate 
training of nurses and lack of pharmacists participation in medical settings.

Keywords

Enteral drug administration
intensive care unit
medication error
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Journal of Research in Pharmacy Practice
Volume 1, Issue 1
August 2012
Pages 37-40

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