Development and Implementation of the MED4TUBE Evidence-Based Care Bundle to Reduce Medication Errors in Enteral Feeding Tubes: A Quality Improvement Study.

Background

Medication administration via enteral feeding tubes is a complex process and is often associated with preventable errors that may affect treatment effectiveness and patient safety.

Objective

This study aimed to develop an evidence-based care bundle and evaluate its impact on medication errors in hospitalized patients.

Methods

This 13-month quality improvement study was conducted in internal medicine wards of a tertiary care hospital and included observation, bundle development, and implementation. Medication administrations via enteral feeding tubes were prospectively observed, and nurse-related factors, including fatigue measured using the Occupational Fatigue Exhaustion Recovery Scale and knowledge levels, were evaluated. A four-parameter care bundle (medication appropriateness, preparation, administration, and monitoring for enteral feeding tubes) was developed using the Knowledge-to-Action framework and Institute for Healthcare Improvement care bundle methodology, including problem identification, evidence synthesis, and expert consensus. After training, medication error rates per dose were compared before and after implementation, using negative binomial regression to account for overdispersion, with results expressed as incidence rate ratios.

Results

A total of 2,064 medication administrations were evaluated in a predominantly geriatric, multimorbid patient population. Preparation and administration errors decreased from 3.8±2.3 to 0.6 ± 0.8 per dose (84% reduction; incidence rate ratio=6.19, 95% confidence interval: 5.44-7.04, p<0.001). Monitoring errors were no longer observed after implementation. Key high-risk practices, including inadequate flushing, inappropriate crushing, and dose loss, were largely eliminated. Error severity shifted toward lower National Coordinating Council for Medication Error Reporting and Prevention categories, with no severe events observed after implementation. No tube occlusions occurred during implementation; bundle adherence was 98.3-100%.

Conclusions

The evidence-based care bundle developed through the framework substantially improved medication safety during enteral feeding tube administration. High adherence supports its feasibility and potential as a standardized quality improvement strategy in clinical practice.