An audit of drug incidents in learning disability group homes

Abstract

The implementation of clinical governance (Department of Health, 1997) requires the review of practice by consideration of complaints and clinical incidents. A systematic review of the clinical incident forms in group homes for those with learning disabilities, within an NHS community trust, highlighted issues for concern. This led to an audit being conducted of drug administration procedures involving examination of records and observation of practice. It demonstrated that there was general adherence to the trust's policies. The audit stimulated debate, and a number of potential areas for action were identified. The review of drug administration with clients who have learning difficulties raised wider questions about the scarcity of evidence in this area to support practice, the culture of client-centred homes and whether monitoring systems are sufficiently robust.

Medication management in intellectual disability settings: A systematic review

“…Several other sources examined medication errors (Stupalski and Russell, 1999; Thurtle, 2000; Zaal et al, 2016). Two of these were descriptive studies while one piloted a tool to reduce such errors (Zaal et al, 2016).…”

“…serum levels of medications or blood pressure) (Zaal et al, 2016), systemic issues (e.g. systems to monitor and improve supply, administration and prevent medication errors) (Stupalski and Russell, 1999) and communication breakdown during the processes of medication administration (Thurtle, 2000). Two sources proposed the collation of medication error data for the purpose of reducing their occurrence (Stupalski and Russell, 1999; Thurtle, 2000) while Zaal et al (2016) recommended that such data should be collected systematically.…”

“…systems to monitor and improve supply, administration and prevent medication errors) (Stupalski and Russell, 1999) and communication breakdown during the processes of medication administration (Thurtle, 2000). Two sources proposed the collation of medication error data for the purpose of reducing their occurrence (Stupalski and Russell, 1999; Thurtle, 2000) while Zaal et al (2016) recommended that such data should be collected systematically. While the literature does not provide evidence per se regarding the use of medication data as an outcome metric, it is notable that one (Stupalski and Russell, 1999) does propose the use of medication error data for the purpose of staff performance evaluation.…”