Improving medication administration in nursing home residents with swallowing difficulties: sustainability of the effect of a multifaceted medication safety programme


  • This article was published online on November 29, 2012. Error was subsequently identified. This notice is included in the online and print versions to indicate that both have been corrected [December 18, 2012].

Correspondence to: C.C.M. Stuijt, ApoMed, Michelangelostraat 62-2 1077CG, Amsterdam, the Netherlands. E-mail:



Crushing solid oral dosage forms is an important risk factor for medication administration errors (MAEs) in patients with swallowing difficulties. Nursing home (NH) residents, especially those on psychogeriatric wards, have a high prevalence of such difficulties.


Six different psychogeriatric wards in two Dutch NH facilities, participating over a total period of 1 year divided into preintervention, implementation, and the first and second evaluation period.

Key measures for improvement

Number of MAEs per number of observed medication administrations calculated for all and three subtypes of MAEs: crushing–uncrushable–medication, inappropriate–technique, and food–drug interactions.

Strategies for change

The intervention included (i) education for nursing staff about crushing medication safely, (ii) a medication administration protocol for patients with swallowing difficulties, (iii) a ‘do-not-crush-medication’ pocket card for the nursing staff, (iv) screening of medication charts by pharmacy technicians on potential crushing problems, and (v) advices on medication charts on safe medication administration to residents with swallowing problems.

Effects of change

The number of crushing uncrushable medication errors, an MAE subtype with the highest potential risk for patient harm, was reduced significantly from 19 (9.6%) to 7 (3.0%; first evaluation period), adjusted odds ratio 0.20 (OR = 95%CI, 0.07–0.55). During the second evaluation period, the proportion crushing uncrushable medications errors was the only outcome that remained significantly lower in comparison with the preintervention period (p = 0.045).

Lessons learned

Introduction of a multifaceted medication safety programme in NH facilities by a pharmacy team is a tool towards safer medication administration practice in residents with swallowing difficulties. Commitment on organisational level is, however, vital to achieve sustainable improvements. Copyright © 2012 John Wiley & Sons, Ltd.