Medicine administration errors in patients with dysphagia in secondary care: a multi-centre observational study

J Adv Nurs. 2011 Dec;67(12):2615-27. doi: 10.1111/j.1365-2648.2011.05700.x. Epub 2011 May 25.


Aim: The aim of this study was to describe the interventions used by nurses when administering oral medicines to patients with and without dysphagia, to quantify the appropriateness of these interventions and the medicine administration error rate.

Background: The administration of medicines to patients with dysphagia is complex and potentially more error prone because of the need to match the medication's formulation to the swallowing ability of the patient.

Method: Data was collected on the preparation and administration of oral medicines to patients with and without dysphagia, including those with enteral feeding tubes, using undisguised direct observation of 65 nurse-led medicine administration rounds on stroke and care-of-the-elderly wards at four acute general hospitals in East of England between 1 March and 30 June 2008.

Results: Of the 2129 medicine administrations observed, 817 involved an error, and of these 313 involved patients with dysphagia. Excluding time errors, the normalized frequency of medicine administration errors for patients with dysphagia was 21.1% compared with 5.9% for patients without. Using a mixed effects model and excluding time errors, there is a higher risk of errors for patients with dysphagia (excluding patients with enteral tubes) compared with those without (P < 0.001) and a further increase in risk of error for patients with enteral tubes compared with dysphagic patients without tubes (P < 0.001).

Conclusion: The increased medicine administration error rate in patients with dysphagia requires healthcare professionals to take extra care when prescribing, dispensing and administering medicines to this group.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Oral
  • Aged
  • Deglutition Disorders / drug therapy*
  • Deglutition Disorders / epidemiology
  • Deglutition Disorders / nursing
  • Dosage Forms
  • England
  • Enteral Nutrition
  • Hospitals, General
  • Humans
  • Medication Errors / classification
  • Medication Errors / nursing
  • Medication Errors / statistics & numerical data*
  • Medication Systems, Hospital / organization & administration
  • Models, Statistical
  • Patient Safety
  • Pharmaceutical Preparations / administration & dosage*
  • Stroke / epidemiology
  • Stroke / physiopathology
  • Time Factors


  • Dosage Forms
  • Pharmaceutical Preparations