Abstract Body: Background: To maximize patient safety in our academic The Joint Commission-designated Comprehensive Stroke Center, dysphagia screening is essential in preventing aspiration. Feeding tubes (FT) allow safe medication administration to patients with identified swallow dysfunction. Thorough review of our dysphagia fallouts revealed oral (PO) route medications ordered and documented as administered PO for patients with “nothing by mouth” (NPO) orders who also had FTs.

Purpose: We developed and implemented a safety alert using the electronic health record (EHR) to ensure right route medication orders. Right route is one of the Five Rights of Medication Administration. Patients NPO with FT require a non-oral route for medication administrations.

Methods: Our team retrospectively analyzed one year of dysphagia fallouts, noting a trend of PO medication administrations documented for stroke patients who had both NPO orders and FT. Review with unit leadership and clinical staff revealed these medications were being appropriately given via FT, indicating the fallouts were documentation, rather than administration, errors. The etiologies of wrong route medication documentations were incorrect medication ordering (providers), EHR medication administration record (MAR) entry (pharmacists), and administration (nurses). An interdisciplinary team partnered with clinical informatics to develop an EHR best practice alert (BPA) for patients NPO with FT, alerting providers to the ordering discrepancy. Evaluation included new PO medication orders entered for Neurology patients NPO with FT before and after BPA implementation.

Results: Our 10-week pre-intervention sample contained 306 new PO medication orders, with 153 (50%) PO MAR entries, and 47 (15.4%) nursing PO administration documentations. The 10-week post-BPA activation sample had 406 new PO medication orders, with 74 (18.2%) PO MAR entries, and 19 (4.7%) nursing PO administration documentations. After dysphagia BPA alert implementation, Χ² comparisons (α=.05) revealed significant reductions in wrong-route PO MAR entries (63.6%, P<.001, Fig.1) and nursing PO administration documentation errors (69.5%, P<.001, Fig.2).

Conclusions: This project suggests a multidisciplinary approach to leverage the EHR to improve right route medication orders and nursing documentation in patients NPO with FT. Other centers may replicate this approach utilizing the EHR to reduce medication documentation errors and improve patient safety.