Accuracy of packaging of dose administration aids in regional aged care facilities in the Hunter area of New South Wales

Abstract

Objective: To audit the accuracy of dose administration aid (DAA) packaging in regional aged care facilities (RACFs) within the boundaries of the Hunter Urban Division of General Practice. Design, participants and setting: Each participating RACF audited one DAA for each resident receiving medication between May and August 2006. Registered nurses compared the contents with the medication chart prepared by the general practitioner and recorded any discrepancies as incidents. Main outcome measures: Number of medication incidents in the provision of DAAs. Results: 297 incidents were detected from 6972 packs for 2480 residents (incident rate of 4.3% of packs and 12% of residents) from 42 participating RACFs. Reasons for incidents included medications missing from a pack (99 occasions), wrong medication dispensed (12), supply of the wrong strength (32), incorrect labelling (7), pharmacies supplying medication that had been ceased by the GP (37), incorrect dosage instructions (32), medications not delivered to the RACF (13). Conclusion: The rate of incidents in DAA packaging in RACFs was high. The error types included incorrect packaging, correct packaging but the DAA was no longer required, and operational problems. Recommendations for improvement include: continuing audit and analysis by RACFs; streamlining of communications among GPs, pharmacists and RACF staff; using electronic methods to chart, order and dispense medications; use of generic names as much as possible; development of guidelines for the supply of medication in DAAs.

The influence of formulation and medicine delivery system on medication administration errors in care homes for older people

“…The prevalence of dispensing errors was threefold higher in the Care Homes' Use of Medicines Study compared with a similar study of dispensing errors in community pharmacies where MDS were excluded,12 although this higher proportion related mainly to one type of MDS 6. Errors when repackaging medicines into MDS for care-home residents have been found to be common in other countries 13 14. In addition, there is concern over the lack of stability data for medicines dispensed into MDS 7 15 16…”

Exploring the past, present and future of care home medicine management systems: pharmacists' perceptions of multicompartment compliance aids

“…MCAs may be perceived to be a safer and more efficient method of medicine administration compared with administering directly from original packaging. However, there is limited literature supporting this and some studies have shown problems associated with their use, including medicine dispensing and administration errors . The Royal Pharmaceutical Societies (RPS) of England and Scotland have cautioned against the routine use of MCAs, calling for a need to review the value of their continued use, taking into account the evidence‐base for the effectiveness of MCAs as one medicine adherence intervention amongst many .…”

Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

“…Wagner et al undertook pilot testing of an electronic incident reporting system in US RACFs and identified lack of clarity of reported data and variation in incident documentation procedures as barriers to reliable and efficient incident reporting [16]. Although studies report a high rate of medication incidents in Australian RACFs, there is an absence of studies that offer insight into medication incident reporting practices [30,31]. The limited literature in this domain highlights the poor quality of information presented in MIR reports that impedes long-term improvements in safety.…”

“…RACFs receive pre-packaged medications from their community pharmacy. These are known as drug administration aids (DAAs) [31]. Each DAA indicates the dosage schedule of each resident.…”