Enhancing Patient Safety and Medication Documentation Accuracy for Stroke Patients with Dysphagia: An Interdisciplinary Approach

Abstract

Background: Accurate clinical documentation is crucial for demonstrating safe and appropriate patient care. Review of dysphagia screening performance revealed oral (PO) route medication documentation for patients with “nothing by mouth” (NPO) diet orders and feeding tubes (FT). Patients NPO with FT require a non-oral route for medication administration. This performance improvement project aimed to decrease medication administration documentation errors (MADE), defined as PO medications documented for patients with NPO diet and current use of a FT, with clinical decision support (CDS) alert functionality. Methods: An interdisciplinary team retrospectively analyzed all dysphagia fallouts, focusing on MADE. Review revealed all MADE medications were appropriately administered via FT, indicating the errors were documentation errors, rather than wrong route medication administrations. Partnering with clinical informatics, our team developed an EHR CDS alert notifying providers of the route discrepancy. A pilot study was completed for patients NPO with FT admitted to Neurology services. Results:  10-week pre-intervention sample included 306 new PO medication orders, resulting in 153 (50%) PO medication administration record (MAR) entries, and 47 (15.4%) MADE. The 10-week post-CDS alert activation sample included 406 new PO medication orders, resulting in 74 (18.2%) PO MAR entries, and 19 (4.7%) MADE. Χ² comparisons (α=.05) demonstrated significant reductions in wrong-route, PO, MAR entries (63.6%, P<.001, fig. 3) and MADE (69.5%, P<.001, fig. 4). Conclusions: This pilot study suggests leveraging the EHR improves right route medication orders, decreasing MADE for patients NPO with FT. Other centers may replicate this approach to improve patient safety and documentation accuracy.