Repeat medication errors in nursing homes: Contributing factors and their association with patient harm

Medication administration in aged care facilities: A mixed-methods systematic review

AIM(S)

To synthesize aged care provider, resident and residents' family members' perspectives and experiences of medication administration in aged care facilities; to determine the incidence of medication administration errors, and the impact of medication administration on quality of care and resident-centredness in aged care facilities.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42023426990.

DATA SOURCES

The AMED, CINAHL, MEDLINE, EMBASE, EMCARE, PsycINFO, Scopus and Web of Science core collection databases were searched in June 2023.

REVIEW METHODS

Included studies were independently screened, selected and appraised by two researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed, with the Mixed Methods Appraisal Tool was used for critical appraisal. Convergent synthesis of data, thematic synthesis and meta-analysis were performed.

RESULTS

One hundred and twenty-eight studies were included (33 qualitative, 85 quantitative and 10 mixed-methods). Five themes were formulated, including 1) Staffing concerns, 2) The uncertain role of residents, 3) Medication-related decision-making, 4) Use of electronic medication administration records and 5) Medication administration errors. Educational interventions for aged care workers significantly reduced medication administration errors, examined across five studies (OR = 0.37, 95%CI 0.28-0.50, p < .001).

CONCLUSIONS

Medication administration in aged care facilities is challenging and complex on clinical and interpersonal levels. Clinical processes, medication errors and safety remain focal points for practice. However, more active consideration of residents' autonomy and input by aged care workers and providers is needed to address medication administration's interpersonal and psychosocial aspects. New directions for future research should examine the decision-making behind dose form modification, aged care workers' definitions of medication omission and practical methods to support residents' and their family members' engagement during medication administration.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

It is important that medication administration in aged care facilities be more clearly acknowledged as both a clinical and interpersonal task. More attention is warranted regarding aged care workers clinical decision-making, particularly concerning dose form modification, covert administration and medication omissions. Resident-centred care approaches that support resident and family engagement around medication administration may improve adherence, satisfaction and quality of care.

IMPACT

What Problem Did the Study Address? Medication administration in aged care facilities is a complex clinical and interpersonal activity. Still, to date, no attempts have been made to synthesize qualitative and quantitative evidence around this practice. There is a need to establish what evidence exists around the perspectives and experiences of aged care workers, residents and resident's family members to understand the challenges, interpersonal opportunities and risks during medication administration. What Were the Main Findings? There is a lack of empirical evidence around resident-centred care approaches to medication administration, and how residents and their families could be enabled to have more input. Dose form modification occurred overtly and covertly as part of medication administration, not just as a method for older adults with swallowing difficulties, but to enforce adherence with prescribed medications. Medication administration errors typically included medication omission as a category of error, despite some omissions stemming from a clear rationale for medication omission and resident input. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The findings of this systematic review contribute to aged care policy and practice regarding medication administration and engagement with older adults. This review presents findings that provide a starting point for aged care workers in regards to professional development and reflection on practice, particularly around clinical decision-making on dose form modification, medication administration errors and the tension on enabling resident input into medication administration. For researchers, this review highlights the need to develop resident-centred care approaches and interventions, and to assess whether these can positively impact medication administration, resident engagement, adherence with prescribed medications and quality of care.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes

AIMS

To identify the safety incident reporting systems and processes used within care homes to capture staff reports of safety incidents, and the types and characteristics of safety incidents captured by safety incident reporting systems.

DESIGN

Systematic review following PRISMA reporting guidelines.

METHODS

Databases were searched January 2023 for studies published after year 2000, written in English, focus on care homes and incident reporting systems. Data were extracted using a bespoke data extraction tool, and quality was assessed. Data were analysed descriptively and using narrative synthesis, with types and characteristics of incidents analysed using the International Classification for Patient Safety.

DATA SOURCES

Databases were CINAHL, MEDLINE, PsycINFO, EMBASE, HMIC, ASSISA, Nursing and Allied Health Database, MedNar and OpenGrey.

RESULTS

We identified 8150 papers with 106 studies eligible for inclusion, all conducted in high-income countries. Numerous incident reporting processes and systems were identified. Using modalities, typical incident reporting systems captured all types of incidents via electronic computerized reporting, with reports made by nursing staff and captured information about patient demographics, the incident and post-incident actions, whilst some reporting systems included medication- and falls-specific information. Reports were most often used to summarize data and identify trends. Incidents categories most often were patient behaviour, clinical process/procedure, documentation, medication/intravenous fluids and falls. Various contributing and mitigating factors and actions to reduce risk were identified. The most reported action to reduce risk was to improve safety culture. Individual outcomes were often reported, but social/economic impact of incidents and organizational outcomes were rarely reported.

CONCLUSIONS

This review has demonstrated a complex picture of incident reporting in care homes with evidence limited to high-income countries, highlighting a significant knowledge gap. The findings emphasize the central role of nursing staff in reporting safety incidents and the lack of standardized reporting systems and processes.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The findings from this study can inform the development or adaptation of safety incident reporting systems in care home settings, which is of relevance for nurses, care home managers, commissioners and regulators. This can help to improve patient care by identifying common safety issues across various types of care home and inform learning responses, which require further research.

IMPACT

This study addresses a gap in the literature on the systems and processes used to report safety incidents in care homes across many countries, and provides a comprehensive overview of safety issues identified via incident reporting.

REPORTING METHOD

PRISMA.

PATIENT OR PUBLIC CONTRIBUTION

A member of the research team is a patient and public representative, involved from study conception.

Adverse event reporting attitude and its individual and organizational predictors among nursing staff: A multisite study in Chinese nursing homes

This study explored the status of adverse event reporting attitudes and its predictors among nursing staff in Chinese nursing homes. A cross-sectional study was conducted with 475 nursing staff, and they completed sociodemographic and facility-related questionnaire, Incident Reporting Attitude Scale, Adverse Event Reporting Awareness Scale, and Nursing Home Survey on Patient Safety Culture. Univariate analysis and multiple linear regression models were performed. The mean score for adverse event reporting attitude was 125.87 (SD=15.35). The predictors included individual variables, such as education level (β=0.129, p = 0.001) and working years (β=-0.102, p = 0.007), and organizational variables, such as patient safety culture (β=0.503, p < 0.001) and adverse event reporting awareness (β=0.261, p < 0.001). These factors explained 35.3 % of total variance. Managers in nursing homes should strengthen team-targeted education and training for nursing staff with longer working years and lower educational backgrounds. Meanwhile, a simplified and non-punitive reporting system should be established to create positive safety management climate.

Evaluation of Medication Incidents in a Long-term Care Facility Using Electronic Medication Administration Records and Barcode Technology

Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.

Medication Identification Device to Reduce Medication Errors in Nursing Homes: A Controlled Pilot Study

A controlled pilot study was performed to evaluate implementation of a medication identification device intended to reduce errors in nursing homes. Naïve observation was used for data collection of medication errors on an intervention unit using the device and a control unit, along with field notes describing observation details. Ten staff were observed administering medications to 70 residents over the study time-frame. Of the 9,099 medication administrations observed (n = 4,588 intervention; n = 4,511 control), 1,068 (12%) errors were identified. The intervention unit had fewer non-time errors versus the control unit, including dose (n = 21 vs. n = 59; p < 0.01), drug (n = 4 vs. n = 21; p <0.01), route (n = 0 vs. n = 4; p < 0.01), and given without order (n = 1 vs. n = 8; p < 0.01). However, time errors were higher on the intervention unit and were often due to late start and interruptions. Non-time errors were due to reliance on memory and nursing judgment. A combination of technology and staff dedicated solely to medication administration likely affected error rate differences. [Journal of Gerontological Nursing, 48(4), 5-11.].

Evaluating the relationship between health information technology and safer-prescribing in the long-term care setting: A systematic review

BACKGROUND

The prevalence of health information technology (HIT) as an adjunct to increase safety and quality in healthcare applications is well known. There is a relationship between the use of HIT and safer-prescribing practices in long-term care.

OBJECTIVE

The objective of this systematic review is to determine an association between the use of HIT and the improvement of prescription administration in long-term care facilities.

METHODS

A systematic review was conducted using the MEDLINE and CINAHL databases. With the use of certain key terms, 66 articles were obtained. Each article was then reviewed by two researchers to determine if the study was germane to the research objective. If both reviewers agreed with using the article, it became a source for our review. The review was conducted and structured based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

The researchers identified 14 articles to include in a group for analysis from North America, Europe, and Australia. Electronic health records and electronic medication administration records were the two most common forms of technological interventions (6 of 14, 43%). Reduced risk, decreased error, decreased missed dosage, improved documentation, improved clinical process, and stronger clinical focus comprised 92% of the observations.

CONCLUSIONS

HIT has shown beneficial effects for many healthcare organizations. Long-term care facilities that implemented health information technologies, have shown reductions in adverse drug events caused by medication errors overall reduced risk to the organization. The implementation of new technologies did not increase the time nurses spent on medication rounds.

A poison information centre can provide important assessment and guidance regarding medication errors in nursing homes: A prospective cohort study

The Danish Poison Information Centre (DPIC) regularly receives inquiries about nursing home residents who have been exposed to a medication error. The aim of this prospective cohort study was to describe and discuss the types and consequences of these errors. Data were collected from 1 March 2018 to 31 March 2019. Registered data included characteristics of caller and resident, data related to the suspected medication error, risk assessment and recommendation. Consequences and clinical outcomes were assessed by follow-up telephone calls. Over the study period, the DPIC was consulted about 145 medication errors occurring at Danish nursing homes. The median number of substances administered by error was two (interquartile range 1-5). Hospitalization was recommended in 21% of cases. In one-third of the cases where consultation with the DPIC was done with the resident either on his/her way to or in hospital, hospitalization was found unnecessary, and the resident could have stayed in accustomed surroundings for observation. Follow-up demonstrated that very few medication errors had a severe outcome. This prospective study illustrates that consulting with a poison information centre can qualify risk assessment and potentially reduce hospital admissions following medication errors in a nursing home setting.

Medication omission rates in New Zealand residential aged care homes: a national description

Background

A medication omission is an event where a prescribed medication is not taken before the next scheduled dose. Medication omissions are typically classed as errors within Residential Aged Care (RAC) homes, as they have the potential to lead to harm if poorly managed, but may also stem from good clinical decision-making. This study aimed to quantify the incidence, prevalence, and types of medication omissions in RAC homes on a national scale, using a New Zealand-based sample.

Methods

We conducted retrospective pharmacoepidemiology of de-identified medication administration e-records from December 1st 2016 to December 31st 2017. Four tiers of de-identified data were collected: RAC home level data (ownership, levels of care), care staff level data (competency level/role), resident data (gender, age, level of care), and medication related data (omissions, categories of omissions, recorded reasons for omission). Data were analysed using SPSS version 24 and Microsoft Excel.

Results

A total of 11, 015 residents from 374 RAC homes had active medication charts; 8020 resided in care over the entire sample timeframe. A mean rate of 3.59 medication doses were omitted per 100 (±7.43) dispensed doses/resident. Seventy-three percent of residents had at least one dose omission. The most common omission category used was ‘not-administered’ (49.9%), followed by ‘refused’ (34.6%). The relationship between ownership type and mean rate of omission was significant (p = 0.002), corporate operated RAC homes had a slightly higher mean (3.73 versus 3.33), with greater variation. The most commonly omitted medications were Analgesics and Laxatives. Forty-eight percent of all dose omissions were recorded without a comment justifying the omission.

Conclusions

This unique study is the first to report rate of medication omissions per RAC resident over a one-year timeframe. Although the proportion of medications omitted reported in this study is less than previously reported by hospital-based studies, there is a significant relationship between a resident’s level of care, RAC home ownership types, and the rate of omission.

Taking one for the team: a reiteration on the role of self-blame after medical error

In a critique of my work on 'taking the blame' as a response to medical errors, my position on the potential goods of individual responsibility and blame is challenged. It is suggested that medicine is a 'team sport' and several rich examples are provided to support the possible harms of practitioner self-blame. Yet, it appears that my critics have misunderstood my demands and to whom they are directed. With this response, I offer several clarifications of my account, as well as a reiteration on the role of self-blame after medical error.

Electronic Medication Administration Records in Long-Term Care Facilities: A Scoping Review

OBJECTIVES

To map the extent, range, and nature of research on the effectiveness, level of use, and perceptions about electronic medication administration records (eMARs) in long-term care facilities (LTCFs) and identify gaps in current knowledge and priority areas for future research.

DESIGN

Scoping review of quantitative and qualitative literature.

SETTING

Literature review.

PARTICIPANTS

Original research relating to eMAR in LTCF was eligible for inclusion.

MEASUREMENTS

We systematically searched MEDLINE, CINAHL, Scopus, ProQuest, and the Cochrane Library and performed general and advanced searches of Google to identify grey literature. Two authors independently screened for eligibility of studies. Independent reviewers extracted data regarding country of origin, design, study methods, outcomes studied, and main results in duplicate.

RESULTS

We identified 694 articles, of which 34 met inclusion criteria. Studies were published between 2006 and 2016 and were mostly from the United States (n=25). Twenty studies (59%) used quantitative methods, including surveys and analysis of eMAR data; 7 (21%) used qualitative methods, including interviews, focus groups, document review, and observation; and 7 (21%) used mixed methods. Three major research areas were explored: medication and medication administration error rates (n=11), eMAR benefits and challenges (n=19), and eMAR prevalence and uptake (n=15). Evidence linking eMAR use and reductions in medication errors is weak because of suboptimal study design and reporting. The majority of studies were descriptive and documented inconsistent benefits and challenges and low levels of eMAR implementation.

CONCLUSION

Further investigation is required to rigorously evaluate the effect of standalone eMAR systems on medication administration errors and patient safety, the extent of eMAR implementation, pharmacists' perceptions, and cost effectiveness of eMAR systems in LTCF.

Drug Administration to the Wrong Nursing Home Residents Reported to the Québec Poison Center: A Retrospective Study

OBJECTIVE

This study examined the association between the administration of drugs to the wrong nursing home residents with a need for hospital treatment or as an indicator of mortality.

DESIGN

A retrospective observational study of medical records from February 1, 2016, to January 31, 2017.

SETTING

Calls made to the Quebec Poison Center.

PARTICIPANTS

Nursing home residents aged ≥65 years.

INTERVENTION(S)

Medication administered to the wrong resident.

MAIN OUTCOME MEASURE(S)

Death, hospital referral and treatment, number of drugs or type of drug classes.

RESULTS

Of the 6282 calls received by the Quebec Poison Center concerning medication errors, 494 cases were included in the retrospective study. Half of the patients (51%) received at least 5 different drugs that were not prescribed for them. Most patients (82%) were asymptomatic at the time of the call to the poison center; however, a third (34%) of the exposures were considered potentially toxic and were treated at the hospital. The most prominent drug classes involved include antihypertensives, antiarrhythmics, and antipsychotics. In particular, almost a quarter (23%) of cases of clozapine maladministration resulted in moderate or severe effects. No deaths were reported.

CONCLUSIONS/IMPLICATIONS

Medication errors in nursing homes are prevalent. The medical provider and probably the poison control center should be consulted as soon as possible when people are aware of administration of medication to the wrong patient, which is considered a medical emergency until proven otherwise. Public policies should seek for better surveillance and prompt intervention. Research should be undertaken to limit errors of drug administration to the wrong nursing home residents.

Factors contributing to serious adverse events in nursing homes

AIMS AND OBJECTIVES

To identify the most common serious adverse events that occurred in nursing homes and their most frequent contributing factors to the improvement of safe nursing care.

BACKGROUND

There is a need to improve safe nursing care in nursing homes. Residents are often frail and vulnerable with extensive needs for nursing care. A relatively minor adverse event in nursing care can cause serious injury that could have been preventable.

DESIGN

This was a retrospective study, with a total sample of data regarding adverse events (n = 173) in nursing homes, concerning nursing care reported by healthcare providers in Sweden to the Health and Social Care Inspectorate. The reports were analysed with content analysis, and the frequencies of the adverse events, and their contributing factors, were described with descriptive statistics.

RESULTS

Medication errors, falls, delayed or inappropriate intervention and missed nursing care contributed to the vast majority (89%) of the serious adverse events. A total of 693 possible contributing factors were identified. The most common contributing factors were (i) lack of competence, (ii) incomplete or lack of documentation, (iii) teamwork failure and (iv) inadequate communication.

CONCLUSIONS

The contributing factors frequently interacted yet they varied between different groups of serious adverse events. The resident's safety depends on the availability of staff's competence as well as adequate documentation about the resident's condition. Lack of competence was underestimated by healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

Registered nurses and assistant nurses need to have awareness of contributing factors to adverse events in nursing care. A holistic approach to improve patient safety in nursing homes requires competence of the staff, safe environments as well as resident's and relative's participation.

Enhancing Patient Safety Event Reporting. A Systematic Review of System Design Features

OBJECTIVES

Electronic patient safety event reporting (e-reporting) is an effective mechanism to learn from errors and enhance patient safety. Unfortunately, the value of e-reporting system (a software or web server based platform) in patient safety research is greatly overshadowed by low quality reporting. This paper aims at revealing the current status of system features, detecting potential gaps in system design, and accordingly proposing suggestions for future design and implementation of the system.

METHODS

Three literature databases were searched for publications that contain informative descriptions of e-reporting systems. In addition, both online publicly accessible reporting forms and systems were investigated.

RESULTS

48 systems were identified and reviewed. 11 system design features and their frequencies of occurrence (Top 5: widgets (41), anonymity or confidentiality (29), hierarchy (20), validator (17), review notification (15)) were identified and summarized into a system hierarchical model.

CONCLUSIONS

The model indicated the current e-reporting systems are at an immature stage in their development, and discussed their future development direction toward efficient and effective systems to improve patient safety.

Evaluation of a hybrid paper-electronic medication management system at a residential aged care facility

Objectives The aims of the study were to investigate discrepancies between general practitioners' paper medication orders and pharmacy-prepared electronic medication administration charts, back-up paper charts and dose-administration aids, as well as delays between prescribing, charting and administration, at a 90-bed residential aged care facility that used a hybrid paper-electronic medication management system. Methods A cross-sectional audit of medication orders, medication charts and dose-administration aids was performed to identify discrepancies. In addition, a retrospective audit was performed of delays between prescribing and availability of an updated electronic medication administration chart. Medication administration records were reviewed retrospectively to determine whether discrepancies and delays led to medication administration errors. Results Medication records for 88 residents (mean age 86 years) were audited. Residents were prescribed a median of eight regular medicines (interquartile range 5-12). One hundred and twenty-five discrepancies were identified. Forty-seven discrepancies, affecting 21 (24%) residents, led to a medication administration error. The most common discrepancies were medicine omission (44.0%) and extra medicine (19.2%). Delays from when medicines were prescribed to when they appeared on the electronic medication administration chart ranged from 18min to 98h. On nine occasions (for 10% of residents) the delay contributed to missed doses, usually antibiotics. Conclusion Medication discrepancies and delays were common. Improved systems for managing medication orders and charts are needed. What is known about the topic? Hybrid paper-electronic medication management systems, in which prescribers' orders are transcribed into an electronic system by pharmacy technicians and pharmacists to create medication administration charts, are increasingly replacing paper-based medication management systems in Australian residential aged care facilities. The accuracy and safety of these systems has not been studied. What does this paper add? The present study identified discrepancies between general practitioners' orders and pharmacy-prepared electronic medication administration charts, back-up paper medication charts and dose-administration aids, as well as delays between ordering, charting and administering medicines. Discrepancies and delays sometimes led to medication administration errors. What are the implications for practitioners? Facilities that use hybrid systems need to implement robust systems for communicating medication changes to their pharmacy and reconciling prescribers' orders against pharmacy-generated medication charts and dose-administration aids. Fully integrated, paperless medication management systems, in which prescribers' electronic medication orders directly populate an electronic medication administration chart and are automatically communicated to the facility's pharmacy, could improve patient safety.

Use of Electronic Medication Administration Records to Reduce Perceived Stress and Risk of Medication Errors in Nursing Homes

Concerns have been raised about the effects of current medication administration processes on the safety of many of the aspects of medication administration. Keeping electronic medication administration records could decrease many of these problems. Unfortunately, there has not been much research on this topic, especially in nursing homes. A prospective case-control survey was consequently performed at two nursing homes; the electronic record system was introduced in one, whereas the other continued to use paper records. The personnel were asked to fill in a questionnaire of their perceptions of stress and risk of medication errors at baseline (n = 66) and 20 weeks after the intervention group had started recording medication administration electronically (n = 59). There were statistically significant decreases in the perceived risk of omitting a medication, of medication errors occurring because of communication problems, and of medication errors occurring because of inaccurate medication administration records in the intervention group (all P < .01 vs the control group). The perceived overall daily stress levels were also reduced in the intervention group (P < .05). These results indicate that the utilization of electronic medication administration records will reduce many of the concerns regarding the medication administration process.

Systematic Review of the Prevalence of Medication Errors Resulting in Hospitalization and Death of Nursing Home Residents

Medication errors (MEs) result in preventable harm to nursing home (NH) residents and pose a significant financial burden. Institutionalized older people are particularly vulnerable because of various organizational and individual factors. This systematic review reports the prevalence of MEs leading to hospitalization and death in NH residents and the factors associated with risk of death and hospitalization. A systematic search was conducted of the relevant peer-reviewed research published between January 1, 2000, and October 1, 2015, in English, French, German, or Spanish examining serious outcomes of MEs in NHs residents. Eleven studies met the inclusion criteria and examined three types of MEs: all MEs (n = 5), transfer-related MEs (n = 5), and potentially inappropriate medications (PIMs) (n = 1). MEs were common, involving 16-27% of residents in studies examining all types of MEs and 13-31% of residents in studies examining transfer-related MEs, and 75% of residents were prescribed at least one PIM. That said, serious effects of MEs were surprisingly low and were reported in only a small proportion of errors (0-1% of MEs), with death being rare. Whether MEs resulting in serious outcomes are truly infrequent, or are underreported because of the difficulty in ascertaining them, remains to be elucidated to assist in designing safer systems.

Optimizing pharmacotherapy in elderly patients: the role of pharmacists

As the world's population ages, global health care systems will face the burden of chronic diseases and polypharmacy use among older adults. The traditional tasks of medication dispensing and provision of basic education by pharmacists have evolved to active engagement in direct patient care and collaborative team-based care. The care of older patients is an especially fitting mission for pharmacists, since the key to geriatric care often lies with management of chronic diseases and polypharmacy use, and preventing harmful consequences of both. Because most chronic conditions are treated with medications, pharmacists, with their extensive training in pharmacotherapy and pharmacokinetics, are in a unique and critical position in the management of them. Pharmacists have the expertise to detect, resolve, and prevent medication errors and drug-related problems, such as overtreatment, undertreatment, adverse drug events, and nonadherence. Pharmacists are also competent in critically reviewing and applying clinical guidelines to the care of individual patients, and in some instances confront the lack of data (common in older adults) to provide the best possible patient-centered care. The current review aimed to depict the evidence of geriatric pharmacy care, demonstrate current impact of pharmacists' interventions on older patients, survey the tools used by pharmacists to provide effective care, and explore their role in pharmacotherapy optimization in elders. The findings of the current review strongly support previous studies that showed positive impact of pharmacists' interventions on older patients' health-related outcomes. There is a clear role for pharmacists working directly or collaboratively to improve medication use and management in older populations. Therefore, in global health care systems, teams caring for elders should involve pharmacists to optimize pharmacotherapy.

Exploring factors that contribute to dose administration aid incidents and identifying quality improvement strategies: the views of pharmacy and nursing staff

BACKGROUND

Dose administration aids (DAAs) organise medicines that have been repacked according to the day of the week and time of the day in which they must be taken. In Australia, DAAs are commonly prepared by pharmacy staff for residential aged care facility (RACF) medicine administration. Although the limited available literature indicates that DAA incidents of inaccurate or unsuitable medicine repacking do occur, there is a paucity of qualitative research identifying quality improvement strategies for this service.

OBJECTIVES

This study aims to investigate the perceived contributing factors to DAA incidents and strategies for quality improvement in RACFs and pharmacies.

METHODS

Health professional perceptions were drawn from three structured focus groups, including six pharmacists, five nurses, a pharmacy technician and a personal care worker. Participants were involved in the preparation, supply or use of DAAs at pharmacies or RACFs that were involved in a previous DAA audit. Transcripts were analysed using thematic analysis.

KEY FINDINGS

Four major themes were identified as contributing to DAA incidents, with quality improvement strategies aligned to those same four themes: communication, knowledge and awareness, medicine handling and attitude. Strategies included improving interprofessional communication and addressing the limitations associated with RACF medicine records; targeting medicine knowledge gaps and increasing awareness of DAA incidents; encouraging greater care when preparing and checking DAAs; and fostering a team mentality among members of the aged care team.

CONCLUSIONS

Recommendations include using current findings to develop multidisciplinary quality improvement initiatives to prevent DAA incidents and to improve the quality of this pharmacy medicine supply service.

[Medication error management climate and perception for system use according to construction of medication error prevention system]

PURPOSE

The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use.

METHODS

The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis.

RESULTS

Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed.

CONCLUSION

The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm

Appropriate and safe use of medications is an important aspect of quality of care in nursing home patients. Because of their complex medication use process, anticoagulants are prone to medication errors in the frail elderly. Therefore, we designed this study to characterize anticoagulant medication errors and to evaluate their association with patient harm using individual medication error incidents reported by all North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Characteristics, causes, and specific outcomes of harmful anticoagulant medication errors were reported as frequencies and proportions and compared between anticoagulant errors and other medication errors using chi-square tests. A multivariate logistic regression model explored the relationship between anticoagulant medication errors and patient harm, controlling for patient- and error-related factors.

Medication incident reporting in residential aged care facilities: limitations and risks to residents' safety

BACKGROUND

Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents' safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs' devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs.

METHODS

The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach.

RESULTS

The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs.

CONCLUSIONS

This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.

Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process

BACKGROUND

Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs.

METHODS

The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process.

RESULTS

The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs.

CONCLUSIONS

Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety.

Factors Associated with Reported Preventable Adverse Drug Events: A Retrospective, Case-Control Study

Background:

It has been reported that error occurs at some point during the medication use process in approximately 6% of medication doses administered in the inpatient setting. An estimated 1-10% of medication errors lead to patient harm; however, factors affecting the risk of harm from a medication error are undefined in the literature.

Objective:

To identify independent factors affecting the risk of reported preventable adverse drug events (ADEs) (ie, medication errors contributing to patient harm) compared to medication errors that did not contribute to patient harm in a diverse patient population.

Methods:

This was a retrospective, case-control study conducted at 3 hospitals within a large health system. Medication error reports from July 1, 2009, through June 30, 2010, were assessed. All reported medication errors determined to have contributed to patient harm were matched 1:1 with a medication error that did not contribute to harm. Data collected through review of the incident report and medical record included patient, provider, medication, and other related factors. Multivariable logistic regression was used to determine the relationship of potential factors to patient harm.

Results:

Of 4321 medication errors reported at study sites, 182 (4%) contributed to patient harm. Factors associated with increased independent risk of harm were 30-day readmission, time of day 0300-0659, and Institute for Safe Medication Practices (ISMP) high-alert medications. Factors associated with decreased independent risk of harm were multiple medication errors, occurrence during February or April, dispensing errors, and pharmacist review of medication order.

Conclusions:

Health systems should develop programs to promote safe, conscientious use of ISMP high-alert medications, promote pharmacist review, control the use of cabinet overrides, and direct provider attention toward recently admitted patients. Efforts should be made to determine factors associated with risk of harm at local levels.

Online medication error graphic reports: a pilot in North Carolina nursing homes

OBJECTIVES

Since 2003, North Carolina nursing homes have been required by state law to report all medication errors, but the nursing homes have not had usable and timely access to their own error data. We created and pilot tested a new online graphic reporting feature to give homes practical and timely reports on their own reported errors for use in improving medication processes.

METHODS

The new graphic reports feature was added to the existing online reporting system and provides immediate access to a set of tables and graphs on all submitted errors. Fifteen nursing homes were recruited to participate in a pilot test of the graphic reports. Key informant interviews were conducted to gather in-depth qualitative information on the use of the reports.

RESULTS

The reports were used primarily for providing information to members of the quality assurance committee and for staff training. Sites had very few technical problems accessing or printing the reports and were able to view them on existing computer systems. Sites with significant numbers of submitted errors in the system reported greater usefulness of the graphics than sites with few errors. Staff turnover at the director of nursing position was the most common reason for low participation at some sites.

CONCLUSIONS

The online graphic reports are a positive, user-friendly next step in providing information to the nursing homes to use in improving patient safety. The information is deemed by the users to be the right content, professional in appearance, and accessible to the nursing home.