Improving Medication Safety in Long-Term Care by Considering Route of Medication Administration

Medication safety is an important issue in long-term care (LTC) settings. Prevention of complications and medication-related problems are essential areas of practice for nurses who administer medications and for those who prescribe them. Although there are numerous medication safety issues to contend with in LTC settings, a common hazard is administering prescribed medications in ways that change their form, such as crushing extended-release tablets. When medications are administered in ways they are not supposed to be patients may have poor outcomes. This article describes insights gleaned from an observational case study and focus group that shed light on this issue. The author advocates for improved communication between prescribers and nurses to ensure medications are administered appropriately and in their intended form, improving patient safety and outcomes in LTC settings. 

Key words: Medication safety, route of medication administration, medication preparation, adverse drug events.
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Medication errors, adverse drug reactions, and medication-related problems are significant issues that tax our healthcare system. In the United States, adverse drug events cost $3.5 billion annually¹; however, these events are not always inevitable. Gurwitz and colleagues² found that approximately 95% of adverse drug reactions are predictable, and approximately 28% are preventable. When adverse drug events occur, they are frequently attributed to polypharmacy and inappropriate prescribing practices.³ To avoid these obstacles to medication safety in long-term care (LTC) settings, it is imperative for all healthcare providers—especially prescribers, pharmacists, physician assistants, nurse practitioners, and nurses administering medications—to improve their understanding of medications and to employ more effective communication practices. Nurse practitioners and physician assistants can be particularly instrumental in this area, as these healthcare professionals can conduct thorough in-depth medication reviews and communicate their findings to the nurses administering medications. They can also instruct persons administering medications on their proper delivery route, ensuring all medications are administered in their intended form, increasing medication safety. This article provides a case example that illustrates how a careful medication review of patient records and open communication between healthcare providers can ensure medications are administered via the appropriate route and that medication formulations are carefully considered to better address patient needs.

Case Study

An 84-year-old woman was admitted to a facility for short-term rehabilitation 3 months earlier, but has remained as an LTC resident. Her medical history includes respiratory failure, chronic obstructive pulmonary disease, lung cancer in remission, cellulitis, chronic pain syndrome, and a fractured hip that was repaired several years before her admission. The patient has a tracheostomy, is dependent on oxygen, and requires a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. The attending nurse is concerned that the resident has suboptimal relief of the pain in her right hip, and she describes the resident’s pain management as a “yo-yo,” with the resident asleep in the morning and then in constant pain all afternoon.

Since the resident’s admission, she has been taking morphine ER/LA (extended-release/long-acting) 30 mg daily; oxycodone and acetaminophen 7.5/325 mg four times daily, which had recently been increased to this dosage by the collaborating physician after pain control was found to be suboptimal; and additional pain medications as needed. All medications are crushed, dissolved in water, and administered via her PEG tube per the standing orders that all her medications may be crushed. The resident’s attending nurse recommends that the nurse practitioner increase the dose of the morphine to improve the resident’s pain management. After assessing the resident and reviewing the need for improved pain management, the nurse practitioner begins to write a prescription for an increase in the resident’s morphine dosage, but stops when she realizes that this medication has been prepared and administered inappropriately by the capsule being opened and the contents dissolved in water and then administered via PEG tube to the resident. Based on these findings, the nurse practitioner discontinues the morphine ER/LA capsules and prescribes a transdermal long-acting narcotic, which when titrated relieves the resident’s pain consistently.

Discussion

When prescribing medications, numerous factors need to be considered, including the patient’s health, comorbidities, medication list, and the route of medication administration. Many older adults in LTC settings may have standing orders that permit medications to be crushed or capsules opened and administered with food. Those requiring nutritional support may have their medications crushed or opened and dissolved in water and delivered via PEG tubes, as occurred with the case patient. Most often, preventable adverse medication-related problems occur at the time of the initial prescription, and once medications are prescribed, they are less likely to be discontinued.⁴ As a result, once a medication is prescribed, it may continue to be administered even if a patient is no longer able to take it in its intended form. In addition, although prescribers may relay the medication orders to those administering the medications, they may not take the preparation of the medication or the route of administration into account; however, as the case study shows, these are important considerations that should not be overlooked. Both the prescriber and the nurse administering the medications need to consider and discuss preparation and administration route to ensure individual patient safety, particularly in the LTC setting, where a higher proportion of patients have difficulty taking medications orally or may develop such difficulties after an initial prescription is made.

In 2012, I was part of a focus group on improving medication safety in LTC settings. The group consisted of 15 registered nurses, all of whom administered medications. The group reported overall that route of administration was their most common concern with regard to safely administering medication. One nurse reported that a prescriber at her facility ordered enteric-coated and long-acting medications for residents who needed to have their medications crushed or crushed and dissolved in water. Although these medication formulations should not be administered in this way, there was resistance from the prescriber with regard to changing the order. The prescriber gave no reasons for the resistance to the nurse, and there was an overall lack of communication between the prescriber and the nurse administering the medications.

Pharmacological advancement has improved the therapeutic delivery of many medications through the development of long-acting formulations; however, these formulations are generally not appropriate for individuals who cannot take the tablet or capsule whole. In some cases, such as in the aforementioned case study, extended-release morphine capsules can be opened and the pellets mixed with food, but they cannot be crushed or dissolved in water. When certain medications are crushed or otherwise altered, their onset of action and absorption changes, which can lead to unsafe outcomes or, as experienced by the case patient, poor pain management. The Institute of Safe Medication Practices maintains a comprehensive list of medications that cannot be crushed and outlines their appropriate route of administration.⁵ Prescribers and administering nurses should familiarize themselves with this valuable resource so that they have a clear understanding of how prescribed medications can be administered (ie, crushed, dissolved in water, mixed with food). In addition, prescribers should carefully review patient records before prescribing medications to ensure they select both the appropriate medications and the correct formulations, and they should then instruct the nurses administering these medications on how to appropriately prepare and give them to residents.

Conclusion 

Nurse practitioners and physician assistants have a great opportunity to inquire about the route medications are administered, review medications being administered, and educate the nurses administering these medications on safe medication practices. When considering the appropriateness of a medication, nurse practitioners and other prescribers need to carefully consider medication formulations and route of administration to maximize the efficacy of medications and prevent adverse events. In addition, once a medication is prescribed, it should be periodically reevaluated, especially in the LTC setting. Patients’ regimens may frequently change, particularly when there is a transition of care or a change in their condition, the latter of which may impede their ability to take oral medications or tolerate certain formulations. In such cases, these medications need to be discontinued and appropriate substitutions made.

References

1.     Institute Of Medicine Committee on Identifying and Preventing Medical Errors. Preventing Medical Errors. Washington, DC:  National Academies Press; 2006:132.

2.     Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1116.

3.     Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.

4.     Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of medication-use process. J Am Geriatr Soc. 2008;56(10):1946-1952.

5.     Mitchell J. Oral dosage forms that should not be crushed. Institute of Safe Medication Practices. www.ismp.org/tools/donotcrush.pdf. Updated October 2012. Accessed December 3, 2012.

Disclosures:

The author reports no relevant financial relationships. 

Address correspondence to:

Raeann G. LeBlanc, DNP, ANP/GNP-BC

University of Massachusetts Amherst School of Nursing

651 N. Pleasant St.

125 Skinner Hall

Amherst, MA 01003

rgleblan@nursing.umass.edu