GPs may be making medication decisions based on records with an average of 10 discrepancies per person compared to facility records… but where are the pharmacists?
There is a need for better systems and greater coordination between pharmacists, GPs and nurses to improve medication safety, an expert in health systems and patient safety has told the Royal Commission into Aged Care Quality and Safety.
Errors associated with medication management are the most common complaint arising from residential aged care facilities, said Professor Johanna Westbrook, Director of the Centre for Health Systems and Safety Research at Macquarie University.
Meanwhile most GPs are unable to access electronic prescribing systems for residents of these facilities, and therefore miss out on decision support such as electronic alerts to potential safety issues.
If GPs fail to update their practice records, there is further risk their medication charts may not be consistent with the resident’s medication chart at the facility, Professor Westbrook added.
She pointed to a study by her research team that found residents on average had nearly 10 discrepancies between their record in the general practice and their record at the aged care facility.
The most frequent discrepancy was medication omission (34.9% of discrepancies) where a medication was listed on the facility chart but not on the GP’s record in their practice.
“Thus a GP referring to their records when contacted by a residential aged care facility (which often occurs over the phone) may in fact have incomplete or inaccurate information to inform their decisions,” said Professor Westbrook.
“Obviously that is mainly a problem when, for example, two drugs might interact with each other, and so you wouldn’t want to prescribe them.”
Information delayed, miscommunicated or lost
The medication management process can be more hazardous in aged care facilities because “you’ve got the GP offsite responsible for the prescribing. You’ve got nurses and care workers delivering, administering the medications, and you have community pharmacists offsite as well,” Professor Westbrook pointed out.
This is completely different from hospitals where you have pharmacists, doctors and nurses all working within the same organisation, she said.
“A lack of coordination between … GPs who prescribe medications, community pharmacists dispensing, registered nurses and care working administering medications and the communication channels that they often rely upon to communicate with each other (mainly telephone, fax machines, paper) introduce risks for information to be delayed, miscommunicated or lost.
“Poor communication practices about medications have been highlighted in a number of overseas studies of long-term care facilities as a contributor to medication error and a failure to adequately monitor medications.”
One of the core ways in which lengthy medication charts are communicated from residential aged care facilities to community pharmacies is still through faxing, she said.
“We’re relying upon things like faxing and this is really quite shocking … [there are] potential risks that communicating information in this way can pose because these are high-volume documents and identification information can often become dislodged from the original document.
“It’s important that the community pharmacist see that they have received the entire chart and that they’re not missing something.”
Better use of electronic data collection systems which interface with GPs, pharmacist and hospitals could reduce adverse events, said Professor Westbrook.
“Paper record systems are no longer fit for purpose and cannot meet future needs.”
Embedding pharmacists into aged care facilities could help support quality use of medicines, pharmacist researcher Dr Janet Sluggett told the Royal Commission this month.
Dr Sluggett, from Monash University’s Centre for Medicine Use and Safety, said non-dispensing pharmacists could conduct comprehensive medication reviews and routine medication chart checks, participate in rounds with GPs to advise on medicines use, and engage in collaborative prescribing with GPs, among other activities.
“Community pharmacists often have very limited clinical information provided to them about the residents for whom they are dispensing medications, and may never actually meet the residents for whom they are dispensing medications,” she said.
“Integrating pharmacists within residential aged care facility will improve provision of medicines information at the point of care.”
Physical separation between pharmacies, GPs and residential aged care facilities means that each stakeholder can spend a considerable amount of time communicating between each other, she added – a point that echoed Professor Westbrook’s comments.
PSA is advocating for more funding for pharmacists to deliver on the range of medication management services within aged care facilities, saying in its submission to the Royal Commission that the limited funding currently available is “grossly inadequate”.
“Pharmacists embedded in facilities can contribute to improving quality use of medicines facility-wide and reducing harm caused by overuse of medicines,” said PSA national president Dr Chris Freeman.
“It has been clear through evidence provided to the Royal Commission that we need to have pharmacists protecting patients from the inappropriate prescribing and use of medicines.”
He added that pharmacists, whether they come from community pharmacy or elsewhere, should be able to perform these activities.
“It’s actually about time on the ground in the facility addressing the multitude of medication management issues,” he told AJP.
Australia’s Chief Medical Officer Professor Brendan Murphy told the Commission in May that embedded pharmacists should be the “highest priority”.