| Safe medication swallowing in Dysphagia: a collaborative improvement project. | |
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MedLine Citation:
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PMID: 18382171 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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Episodes of choking during medication administration to patients with dysphagia prompted a chart audit and caregiver interview to identify system problems that allowed inappropriate drug administration to occur. Sixty elderly patients residing on two patient care areas in a 500-bed complex continuing care facility were studied. The audit explored the actual nursing medication administration methods and compared this to the information obtained from various communication tools including instructions that appeared on the medication administration record (MAR), the current diet order, the recommendations of the speech-language pathologist (SLP) and comments on the nursing care plan. The audit yielded a number of discrepancies between nursing actions and the instructions obtain from these sources. We proposed that changes to the process of communicating medication swallowing recommendations among team members would lead to greater patient safety. Major practice changes included the use of standardized language by the SLP when making recommendations, the writing of SLP recommendations in the doctor's orders, the inclusion of SLP recommendations on the MAR and the creation of a "dysphagia alert" on the pharmacy computer system. An educational intervention was conducted to implement process changes. Its effectiveness was evaluated using a pre- and post-test and a participant satisfaction survey. A post-implementation audit showed compliance with the practice change. In summary, process changes were implemented to improve compliance with SLP medication-related swallowing recommendations and to prevent the inadvertent prescribing, dispensing or crushing of sustained-release medications in patients with dysphagia. |
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Authors:
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Lawrence D Jackson; Jane Little; Edward Kung; Evelyn M Williams; Krystyna Siemiatkowska; Suzanne Plowman |
Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Healthcare quarterly (Toronto, Ont.) Volume: 11 ISSN: 1710-2774 ISO Abbreviation: - Publication Date: 2008 |
Date Detail:
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Created Date: 2008-04-02 Completed Date: 2008-07-17 Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 101208192 Medline TA: Healthc Q Country: Canada |
Other Details:
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Languages: eng Pagination: 110-6 Citation Subset: H |
Affiliation:
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Aging and Veterans Care, Sunnybrook Health Sciences Centre, Toronto, Ontario. Lawrence.Jackson@sunnybrook.ca |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Administration, Oral Airway Obstruction / prevention & control* Cooperative Behavior* Deglutition Disorders / drug therapy* Humans Interviews as Topic Medical Audit Safety Management* |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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