Dysphagia is simply defined as difficulty in swallowing and can include saliva, liquids and foods of all consistencies (Murray and Carrau 2006), as well as medications. Dysphagia is a symptom of many disorders with prevalence figures varying depending on the population studied, associated medical disorders and the diagnostic tool used (Wilkins et al 2007). An indication of the size of the problem is that in 2007-08, 22,510 patients were admitted to hospitals in the UK with a primary diagnosis of dysphagia ( Hospital Episode Statistics (HES 2009); during 2005 at least 28,095 patients in the UK received home enteral tube feeding (Whiteand Bradnam 2006), a treatment frequently used to manage swallowing problems. The prevalence of swallowing impairment increases with advancing age (Nilsson et al 1996).
This is partially because older people are more likely to have conditions such as stroke, neuromuscular disorders and obstructive lesions that can result in dysphagia and partially as a result of the ageing process itself which can negatively affect all three phases of the swallowing process (Kelly and Wright 2009). As a consequence, it is suggested that 70% to 90% of older people have some degree of swallowing dysfunction (Murray and Carrau 2006) and with the proportion of older people in the population rising, dysphagia is becoming an increasingly significant problem .
Medicine administration is an important nursing role and in recognition of this the Nursing and Midwifery Council (NMC) has published Standards for Medicines Management(NMC 2008a), designed to promote safe administration of medicines – an area of considerable concern in UK hospitals (Department of Health (DH) 2000).
In 2007, 72,482 medication incidents occurred in England and Wales, 50% of which occurred during medicine administration (National Patients Safety Agency (NPSA) 2009). Medicine administration errors (MAEs) can be defined as ‘... mistakes associated with medicines and intravenous infusions that are made during the prescription, transcription, dispensing and administration phases of medicine distribution’ (Wolf 1989).
Observational studies suggest that the MAE rate for oral medicines in the UK range from 3% to 8% (Dean et al 1995, Ridge et al 1995, Gethins 1996, Cavell and Hughes 1997, Ho et al 1997, Ogden et al 1997, Taxis et al 1999). A more recent UK-based study found an error rate of 25.9% (369 errors in 1,423 opportunities) on two older people wards in a psychiatric hospital in Northampton (Dickens et al 2008); the same team found that medication errors were more often associated with patients with swallowing difficulties than those without (Haw et al 2007).
These results are not surprising as dysphagia affects patients’ ability to take their oral medication. If patients are unable to swallow tablets and capsules then either medicines need to be omitted and given by an alternative route (Beckwith et al 2004), or in a different formulation (White and Bradnam 2006). When this is not possible a common response is to crush tablets or open capsules and mix the residue with food or to administer it via an enteral feeding tube (Mistry et al 1995, Belknap et al 1997, Tissot et al 1999, Wright 2002a, Kirkevold and Engedal 2005, Barnes et al 2006, Paradiso et al2002, Williams 2008).
However, in altering the formulation of a medication it becomes unlicensed, resulting in the prescriber, dispenser and administrator becoming liable for any harm that occurs from taking the medicine (Royal Pharmaceutical Society (RPS) 2004, Wright 2002b, Griffith and Davies 2003, Griffith 2005).
The medication’s pharmacokinetics, therapeutic efficacy and side effect profile can be affected (Thomson et al 2000) which has, on occasion, been fatal (Schier et al 2003).