Abstract
Background: Enteral nutrition (EN) therapies are prescribed for hospitalized patients who are not able to maintain adequate nutrition through the oral route. If prescribed EN therapies are not administered or monitored in the prescribed manner, or the EN therapies are not accurately prescribed, patients are at-risk for harm. Medical errors and safety events related to EN therapy have been reported but are under-reported. Registered Nurses verify, administer, document, monitor, and assess impacts of prescribed EN therapies for hospitalized patients. Best practices such as standardized EN order sets, standardized EN administration and documentation systems, use of medication use process (MUP) for EN therapies, and use of 6-rights of medication administration when nurses administer EN are recommended to improve safety and effectiveness of care. Unfortunately, many health systems in the United States have fragmented ordering, dispensing, administering, documenting, monitoring, and tracking of enteral nutrition therapies for hospitalized patients. The purpose of this quality project is to determine the number, type, and severity of safety events related to the provision of EN reported to the National Center for Patient Safety/Veterans Health Administration Joint patient Safety Reporting (JPSR) system during 2018-2020 and provide workable recommendations from the literature to improve nursing practice and patient safety.
Methods: A multidisciplinary team queried the JPSR system between 2018-2020 using keywords related to EN use. The team reviewed the number, types, and severity of reported events, subtypes, and safety codes as categorized by NCPS. The team categorized the events in one or more of the Medication Use Process (MUP) steps based on review of the narrative details.
Results: From 2018-2020, the JPSR system received 1227 safety events related to EN. The majority (94%) of actual safety events were labeled as grade 1 (minor), although 47% of potential safety events were categorized as grade 2 or above (more severe). These included incorrect product; incorrect rate or dosage; incorrect route; wrong patient; errors in patient monitoring; supply/equipment malfunction; miscommunication at transitions of care; or EN formula not delivered/unavailable.
Conclusion: Nursing advocacy in practice and policy is needed to improve the standardization, safety, and effectiveness of the nursing process and enteral nutrition care for malnourished hospitalized patients.
Notes
References:
Citty SW, Chew M, Hiller LD, Maria LA. Enteral nutrition: An underappreciated source of patient safety events. Nutr Clin Pract. 2024;39(4):784-799. doi:10.1002/ncp.11153
Chew MM, Rivas S, Chesser M, Landas N, Schaefer S, Enright A, Olsen J, Meacci K, Luevano V, Harraway D, Citty SW. Improving Administration and Documentation of Enteral Nutrition Support Therapy in a Veteran Affairs Health Care System: Use of Medication Administration Record and Bar Code Scanning Technology. J Patient Saf. 2023 Jan 1;19(1):23-28. Available at: https://pubmed.ncbi.nlm.nih.gov/36538338/
Citty SW, Kamel A, Garvan C, Marlowe L, Westhoff L. (2017). Optimizing the electronic health record to standardize administration and documentation of nutritional supplements. BMJ Qual Improv Rep. 2017 Feb 8;6(1).
Citty SW, Bjarnadottir RI, Marlowe BL, Jones S, Lucero RJ, Garvan CW, Kamel AY, Westhoff L, Keenan G. Nutrition Support Therapies on the Medication Administration Record: Impacts on Staff Perception of Nutrition Care. Nutr Clin Pract. 2021 Jun;36(3):629-638.
Costello RB, Deuster PA, Michael M, Utech A. Capturing the Use of Dietary Supplements in Electronic Medical Records: Room for Improvement. Nutr Today. 2019;54(4):144-150.
Boullata JI, Carrera AL, Harvey L, Escuro AA, Hudson L, Mays A, McGinnis C, Wessel JJ, Bajpai S, Beebe ML, Kinn TJ, Klang MG, Lord L, Martin K, Pompeii-Wolfe C, Sullivan J, Wood A, Malone A, Guenter P; ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition. ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]. JPEN J Parenter Enteral Nutr. 2017 Jan;41(1):15-103.
Sigma Membership
Alpha Theta
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Other
Keywords:
Acute Care, Policy and Advocacy, Interprofessional or Interdisciplinary, Enteral Nutrition
Recommended Citation
Citty, Sandra Wolfe; Chew, Mary; Hiller, Lynn; and Maria, Lisa, "Enteral Nutrition Safety for Hospitalized Patients: A Call to Action for Nursing" (2025). International Nursing Research Congress (INRC). 180.
https://www.sigmarepository.org/inrc/2025/presentations_2025/180
Conference Name
36th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Seattle, Washington, USA
Conference Year
2025
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Enteral Nutrition Safety for Hospitalized Patients: A Call to Action for Nursing
Seattle, Washington, USA
Background: Enteral nutrition (EN) therapies are prescribed for hospitalized patients who are not able to maintain adequate nutrition through the oral route. If prescribed EN therapies are not administered or monitored in the prescribed manner, or the EN therapies are not accurately prescribed, patients are at-risk for harm. Medical errors and safety events related to EN therapy have been reported but are under-reported. Registered Nurses verify, administer, document, monitor, and assess impacts of prescribed EN therapies for hospitalized patients. Best practices such as standardized EN order sets, standardized EN administration and documentation systems, use of medication use process (MUP) for EN therapies, and use of 6-rights of medication administration when nurses administer EN are recommended to improve safety and effectiveness of care. Unfortunately, many health systems in the United States have fragmented ordering, dispensing, administering, documenting, monitoring, and tracking of enteral nutrition therapies for hospitalized patients. The purpose of this quality project is to determine the number, type, and severity of safety events related to the provision of EN reported to the National Center for Patient Safety/Veterans Health Administration Joint patient Safety Reporting (JPSR) system during 2018-2020 and provide workable recommendations from the literature to improve nursing practice and patient safety.
Methods: A multidisciplinary team queried the JPSR system between 2018-2020 using keywords related to EN use. The team reviewed the number, types, and severity of reported events, subtypes, and safety codes as categorized by NCPS. The team categorized the events in one or more of the Medication Use Process (MUP) steps based on review of the narrative details.
Results: From 2018-2020, the JPSR system received 1227 safety events related to EN. The majority (94%) of actual safety events were labeled as grade 1 (minor), although 47% of potential safety events were categorized as grade 2 or above (more severe). These included incorrect product; incorrect rate or dosage; incorrect route; wrong patient; errors in patient monitoring; supply/equipment malfunction; miscommunication at transitions of care; or EN formula not delivered/unavailable.
Conclusion: Nursing advocacy in practice and policy is needed to improve the standardization, safety, and effectiveness of the nursing process and enteral nutrition care for malnourished hospitalized patients.
Description
Registered Nurses assess, plan, implement, and evaluate nutrition care for hospitalized patients. Safety events related to prescribed enteral nutrition therapy have been reported; however, they are thought to be under-reported. During a 2-year period, over 1200 safety events were submitted to the Joint Patient Safety Reporting (JPSR) system related to enteral nutrition therapy. Nursing advocacy is needed to ensure the safety of enteral nutrition therapy for hospitalized patients.