We have recognized for a long time that in patients with enteral tubes, often times the orders are not updated to specify "per enteral tube" but remain as "po". The pharmacy team verifying orders do not know that meds are being given via tube and thus are often not able to identify problems proactively. We recently had a serious safety event related to Flomax being opened and placed into a G-tube, which resulted in a clogged tube and necessitating replacement of the tube twice, the second time under sedation (thus the severity rating of the event).
We are a Cerner hospital- has anyone utilized rules or other to navigate this issue?

Thank you in advance!

Julie Botsford
Medication Safety Officer-Munson Healthcare