Detection of medication errors in hospital discharge communications of patients on Enteral nutrition

Matteo Sestili, Letizia Ferrara, Serena Logrippo, Roberta Ganzetti

Research output: Contribution to journalArticlepeer-review


Introduction: The correct administration of oral drugs to patients receiving enteral tube feeding presents a special challenge, as many errors are made at the administering stage (e.g. crushing of dosage forms that should not be crushed). This study was undertaken to evaluate the medication administration errors in patients with enteral nutrition discharged from a geriatric unit of the Italian National Research Centers on Aging (INRCA).

Materials and Methods: Five hundred and eighty discharge letters were screened, and 50 (8.6%) related to patients on enteral nutrition were studied with a focus on medication delivery, in order to highlight all medication errors.

Results: Eighty-six medication errors were detected. The most common error was “prescription of the wrong formulation” (69.8%) when a formulation suitable for administration by enteral feeding tube was commercially available.

Conclusions: Given the large number of errors detected, we consider a multidisciplinary program, including the intervention of a pharmacist, necessary to promote the correct administration of drugs through an enteral feeding tube. This program may consist of training nurses, detection of drug-nutrient interactions, daily ward visits, meetings with the patient and family to provide detailed instructions about drug administration through a feeding tube as reported in the discharge letter, and preparation by the pharmacy of liquid formulations, if not commercially available, suitable for administration through enteral feeding tubes.

Original languageEnglish
Pages (from-to)152-154
Number of pages3
JournalNutritional Therapy and Metabolism
Issue number3
Publication statusPublished - Jul 1 2014


  • Discharge letter
  • Enteral nutrition
  • Medication errors

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Nutrition and Dietetics


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