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The Epidemic of Medication Errors via Enteral Tube that MAHC Refuses to See

The Consequences of Mixing Negligence and High Risk

How is it possible that a Canadian hospital subjected an elderly, high-risk patient to more than 4,200 medication errors, endangering her recovery, if not her life, each day for nearly three months?  Here is one of the answers.

Complete breakdown in enteral drug process

When a patient cannot swallow after an injury or surgery, an enteral feeding tube is frequently inserted into the stomach to allow for the administration of nutrition and medication.  This was the case for our mother.  It is an intervention that is clinically recognized as placing a patient in a much higher category of risk, and therefore raises the level of care and attention required.  Unfortunately for our mother, at MAHC these precautions were never heeded.

For the three months our mother was at MAHC, just about every aspect of care involving her enteral feeding tube was mishandled.  In addition to providing inadequate nutrition that left her severely malnourished by the end of her stay, the hospital improperly prepared and administered her medication in a manner that was contrary to universally accepted evidence-based recommendations and risked serious drug interactions and complications.

Multiple errors with each of 1,100 doses

Every one of some 1,100 doses of medication our mother received through her enteral feeding tube was compromised by multiple errors as a result of unsafe and unsterile practices that were contrary to evidence-based guidelines and well-documented warnings from leading authorities on nutrition and medication via enteral feeding systems, including the American Society for Parenteral and Enteral Nutrition (ASPEN).  Its recommendations are endorsed by the highly respected Institute for Safe Medication Practices (ISMP) Canada.

Medications improperly crushed, mixed and administered together

In preparing our mother’s medications, nursing staff did exactly what they were not supposed to do.  They crushed multiple drugs together (usually in a busy hallway in close proximity to other patients, staff, visitors and cleaning activity) improperly mixed them with liquid medications, diluted this mixture with tap water drawn from a dirty bathroom sink, and drew the mixture into a single syringe.  The contents of the syringe were then injected directly into our mother via her enteral feeding tube.  This practice typically occurred six separate times each day of our mother’s hospitalization.  These are recognized errors in medication preparation and administration.

Hospital practices warned against by experts


Dr. Joseph Boullata, one of the world’s most respected experts in the field of enteral medication administration and an author of the ASPEN Guidelines, warns that crushing and mixing medications together risks changing the molecular structure of the drugs, making their compatibility and stability unpredictable. Resulting risks include drug interactions, altered drug efficacy and toxicity. Each drug must be prepared and administered individually.  (See Table 1.)  In addition, sterile or purified water is to be used for diluting the medication.  The crushing and mixing process must occur using aseptic techniques in a sterile environment.  A busy hospital hallway is not a sterile environment.  

Improper mixing changes drug composition

When nursing staff mixed together as many as nine of our mother’s prescription medications at a single time and administered them concomitantly, they were creating entire new drug entities with unknown pharmacodynamic properties.  The fact of the matter is that no physician, no pharmacist and no nurse at MAHC had the foggiest idea what the true combined chemical composition of these drug mixtures was, what interactions they would cause, or how they would act upon the body’s organs at different times.  Even drugs which the manufacturer warns must never be crushed, like diltiazem, were crushed and mixed with other medications and injected into our mother.  Other drugs that pharmacology experts warn are to be avoided in combination because of the risks that combination presents were also crushed, mixed together in the same syringe and injected into our mother at the same time.

Contraindicated and multiple serotonergic drugs mixed together

During our mother’s stay at MAHC, she was prescribed two drugs (buspirone and sertraline) that are known to increase serotonergic activity.  The risks they present individually, much less in combination, of serotonin syndrome, a potentially fatal condition, are significant and well recognized in pharmacological warnings. Avoiding the combined use of serotonergic-augmenting drugs is essential.  Not only were these drugs given to our mother in combination, but the crushed powder from buspirone pills was mixed with the powdered contents of sertraline capsules.  Diltiazem, a third drug that is known to increase certain buspirone levels by five-fold, was also added to this mixture.  Taking buspirone with diltiazem is contraindicated because of the resulting increase in levels which in turn present even greater risk for enhanced serotonergic activity.  At MAHC there was never any mention of the risks involved with these drugs and members of the care team, including the hospital’s pharmacists, claimed to be unaware of any potential adverse side-effects when we inquired.

Unsterile mixing and compounding risks contamination

Our mother’s medications were prepared, crushed and mixed together in the unsterile environment of a busy hospital hallway, adjacent to an active stairwell and a soiled linen storage room.  This occurred some six times a day, each time making our mother’s medications susceptible to airborne and contact contamination from other patients, staff, visitors and hospital cleaning activities, and placing an already immunocompromised patient at even greater risk.  

Tap water from dirty bathroom sink used with medication

On top of preparing medication in an unsterile environment, nursing staff diluted the drugs with tap water from a dirty sink in our mother’s cluttered bathroom, where used enteral feeding bags were commonly discarded and clothes soiled with vomit were rinsed and left along with other unsanitary items.  Even when it is not being drawn from such a compromised source, tap water should not be used as a diluent for medications delivered through enteral feeding tubes, experts warn, because of the risk of contamination from heavy metals and other substances commonly found in tap water.  ASPEN and ISMP alerts advise that sterile/purified water be used.  

All hydration quality compromised

All of the hydration provided to our mother, apart from the “free water” found in the enteral nutrition formula, came from this dirty sink as well.  Practice recommendations warn of the need to use sterile water for this purpose, too, in high-risk patients, like our mother, on enteral support.

Aseptic techniques ignored

Nursing staff failed to use gloves as part of required aseptic techniques when preparing and handling medication and enteral products, and repeatedly reused syringes that were labeled by the manufacturer as single-use only.  The mortar and pestle, and other pill crushing devices in which the medications were ground, were not cleaned with soapy water or other means before and after each use, were often left standing in the hospital room unprotected, and occasionally had to be brought from another patient care area.  Residue left from crushed pills can lead to incompatible drug reactions.

MAHC still sees nothing wrong

Yet, for all these violations of safety practices and departures from well-established guidelines that permitted the unsafe and unsterile handling, compounding and mixing of multiple drugs for every dose of medication our mother received through her enteral system, MAHC still maintains medication was administered according to physician orders and clinical protocols and that no medication errors were reported.  They have also insisted that our mother’s care was “appropriate.”   When presented with the specific issue of how it prepared and administered our mother’s medication, MAHC’s board of directors, CEO and top clinical leadership have nothing to say and will not respond. The shocking inattentiveness to safety and breakdowns in care and supervision at MAHC that exposed our mother to needless risk and unpredictable drug interactions and complications has now been replaced by a fog of willful blindness on the part of those at its top.  The implications of that mindset are staggering and go a long way to explaining how our mother’s horrific ordeal was allowed to occur.