Aug 06, 2018

Why medication errors happen in aged care homes, and what can be done about it

Medication errors are a common problem in aged care. Despite all the best intentions, errors all too often slip through the system.

A survey of 700 aged care nurses by the NSW Nurses and Midwifery Union found that 83 per cent of nurses had witnessed medication errors.

Nurses reported medication being given to the wrong patient, ear drops being put in a resident’s eyes, and it was even reported that a cleaner had dispensed medicine in one case.

It’s hardly surprising then that medications management was one of the top five complaints received by the Aged Care Complaints Commissioner in 2015/16.

Medication errors “the bain of residential aged care”

Kate Carnell, lead author of the Carnell and Patterson review of aged care quality regulations, recently said that medication errors are “the bain of residential aged care”.

“It has always been thus,” said Ms Carnell, who trained as a pharmacist. She said older people often have polypharmacy, and often have a number of health conditions. In aged care, they may no longer have the GP they had for 30 years that “knows them backwards”, instead they may only see a new visiting GP.

“Nurse practitioners are fantastic in this space, but the fact is that polypharmacy is a really complex space and something that we need to address.”


What are the causes of medication errors in aged care?

Inadequate training, time constraints, and relying on paper-based systems are some of the common reasons given for medication errors in residential aged care.

By replacing paper-based systems with automated medication systems, many nursing homes have been able to dramatically decrease their rate of medication errors.

Automated medication systems: “medication errors have gone down dramatically”

Maroubra Shores aged care facility, which is operated by Montefiore, introduced Best Health Solutions’s BESTmed automated Medication Management system 12 months ago.

Maroubra Shores’ Manager, Andrea Van Gramberg, said the nursing home had some inefficiencies in the way it was administering medications, collating data, and finding trends, so it decided to automate its systems.

Since the BESTmed system was introduced, medication errors have gone down “dramatically”, she said.

The flow on benefits of automated medication systems

Maroubra Shores has also noted a number of other advantages of automating its medication systems.

Data from BESTmed has also allowed the nursing home to identify trends. For example, if a spike in the delivery of pain medication to a resident is observed, they can organise for the resident to see the doctor to try to identify the cause of the pain.

Ms Van Gramberg also said that flexibility can be built into the system. At Maroubra Shores, residents don’t have to attend the 8am breakfast. BESTmed System allows for leeway with the timing of the morning medication rounds, allowing residents to wake naturally.

“We can tailor the system to allow flexibility for the residents’ routines,” she said.

Double checks are also built into the BESTmed system. For example, if a medication is not signed off within a certain time frame, the manager is notified. The double checks provides another layer of information that helps Ms Van Gramberg to “nip any problems in the bud”.

Similarly, if the effectiveness of a medication hasn’t been monitored, management is alerted, providing them with useful information about what is happening on the floor.

The BESTmed system helps nursing homes follow best practice. For example, injectable Warfarin and Insulin medications require sign off by two staff, adding a check to the system that “reinforces best practise”.

But the biggest change is the “improved efficiencies with scripts”, Ms Van Gramberg said.

“Less time is spent chasing up doctors for scripts. We’ve been able to tailor the medication rounds. We know which medication rounds are coming up. It also helps with agency staff,” she said.

“The feedback on the floor from the RNs is it’s much easier to know where they are up to with medications.”

Ms Van Gramberg said that though she no longer has to contact them very often, BESTmed’s support team provides “very hands on information that helps us with the residents’ care”.

Ms Van Gramberg said she would “definitely” recommend BESTmed’s system.

Best Health Solutions: committed to quality and safe use of medication in aged care

The aged care industry, as with so many other industries, will gradually continue to shift away from paper-based systems and towards greater automation. Sam Hijazi, co-founder of Best Health Solutions, says the company is committed to improving the quality and safe use of medicine in residential aged care and has recently launched a doctor module that will allow doctors to chart medications electronically. This will further reduce inefficiencies and bring the Aged Care Facility, Doctor and Pharmacy a single view of a resident’s medication profile.

The efficiencies and accuracy that flow from automated systems will be the key to reducing rates of medication errors in the aged care industry in future.

For more information contact Best Health Solutions.

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  1. This article glosses over one important fact and that is (the easily observable) practice of PCAs administering medications illegally. This is happening because there are not enough Registered Nurses around to properly supervise the taking of medications by older people who in general (especially when they are sick) take a long time to swallow tablets. Some older people pretend to swallow tablets and then spit them out later. The solution to this problem is to increase the number of Doctors per facility so that older people are not taking medications they don’t need and increase the number of RNs so that medications can be administered safely.

    1. If all residents made use of pharmacy packed medication ( Webster packs), surely that would help to reduce the number of errors made on the floor with unauthorised carers administering or at the very least, minimum errors being made???

  2. We all know this is a serious issues. Serious health implications and serious costs to the health system for getting this wrong….I would suggest that RN’s should be the only people involved in the dosing but the reality is the PCA’s are the ones that will have the most impact over adherence….. What is going to be quicker trying to get more RN’s into the system or trying to raise teh level of PCA’s and itneractions with medicines….Happy to hear your thoughts @niemesm


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