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

Abstract

BackgroundMedication 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.MethodsThe 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.ResultsThe 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.ConclusionsThis 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.

Drug-related problems and their clinical interventions in a Ghanaian teaching hospital

“…Majority of the interventions related to drug therapy changes. Though this study evaluated handwritten reports, it is comparable to evaluations done on electronic incident reports [8,9]. The categories of drugs most often associated with drug error reports were similar to those reported from previous studies and included cardiovascular agents [10,11], anti-infectives [11,12], and central nervous system agents [10,13], suggesting that future strategies for reducing drug errors could target these agents.…”

The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial

“…Medication administration is a fundamental and important nursing and carer task in resident care and safety . Ensuring safe medication administration in RACHs is complicated by high rates of polypharmacy, cognitive and behavioural issues and age and/or disease‐related physiological decline . These factors contribute to substantial time requirements for the medication administration process, accounting for approximately one‐third of nursing time …”

“…6,7 Ensuring safe medication administration in RACHs is complicated by high rates of polypharmacy, cognitive and behavioural issues and age and/or disease-related physiological decline. 8,9 These factors contribute to substantial time requirements for the medication administration process, accounting for approximately one-third of nursing time. 7 Oral medications are the preferred formulation type as they are convenient and non-invasive, and generally manageable for most residents with minimal assistance from staff.…”

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study

“…Existing medication incident reporting systems in RACFs are poorly designed and focus on individual responsibility for errors 29. They have limited capacity to improve safety because they only identify factors that are proximal to the incident 29.…”

“…Existing medication incident reporting systems in RACFs are poorly designed and focus on individual responsibility for errors 29. They have limited capacity to improve safety because they only identify factors that are proximal to the incident 29. While a single action or omission by a GP may appear as the immediate cause of a prescribing error, investigations often ignore the latent weaknesses in the working environment that promote or permit errors 24 30.…”