To err is human: medication patient safety in aged care, a case study

Abstract

Purpose The purpose of this paper is to explore an identified medication error using a root cause analysis and a clinical case study. Design/methodology/approach In this paper the authors explore a medication error through the completion of a root cause analysis and case study in an aged care facility. Findings Research indicates that medication errors are highly prevalent in aged care and 40 per cent of nursing home patients are regularly receiving at least one potentially inappropriate medicine (Hamilton, 2009; Raban et al., 2014; Shehab et al., 2016). Insufficient patient information, delays in continuing medications, poor communication, the absence of an up-to-date medication chart and missed or significantly delayed doses are all linked to medication errors (Dwyer et al., 2014). Strategies to improve medication management across hospitalisation to medication administration include utilisation of a computerised medication prescription and management system, pharmacist review, direct communication of discharge medication documentation to community pharmacists and staff education and support (Dolanski et al., 2013). Originality/value Discussion of the factors impacting on medication errors within aged care facilities may explain why they are prevalent and serve as a basis for strategies to improve medication management and facilitate further research on this topic.

Interventions to Enhance Medication Safety in Residential Aged‐care Settings: An Umbrella Review

“…Staff education Forsetlund et al, 1 Alldred et al, 4 Kröger et al, 3 Lee et al, 5 Loganathan et al, 6 Thompson Coon et al, 9 Almutairi et al, 13 Ali et al 11 Educational meetings and workshops for RACS staff…”

“…Medication review Forsetlund et al, 1 Chen et al, 2 Kröger et al 3 Physician (GP and geriatrician) involvement in the medication review Forsetlund et al, 1 Alldred et al, 4 Chen et al, 2 Kröger et al, 3 Lee et al, 5 Loganathan et al, 6 Sadowski et al 7 Thiruchelvam et al, 8 Thompson Coon et al, 9 Verrue et al, 10 Ali et al, 11 McDerby 12 Pharmacist involvement or pharmacist-led medication review…”

“…Forsetlund et al, 1 Chen et al, 2 Kröger et al, 3 Thiruchelvam et al, 8 Almutairi et al 13 Multidisciplinary medication review teams (physicians, pharmacists, nursing staff and other allied healthcare professionals)…”

“…Concerns about medication safety in residential aged‐care settings (RACS) are recognised worldwide by policymakers, academic researchers and the media. Various studies exploring medication safety in RACS report a higher rate of medication errors than in hospital settings 2–4 . Medication errors can be defined as any error that occurs during prescribing, dispensing or administering medications and results in the failure to give a patient the correct drug or proper dosage 5 .…”

“…Various studies exploring medication safety in RACS report a higher rate of medication errors than in hospital settings. [2][3][4] Medication errors can be defined as any error that occurs during prescribing, dispensing or administering medications and results in the failure to give a patient the correct drug or proper dosage. 5 Medication safety in RACS is an issue of heightened concern because residents are generally frail, with multimorbidity and polypharmacy, which increases the risk of adverse drug events (ADE).…”