Meds errors in aged care facilities: part two


Gerard Stevens, founder and managing director of Webstercare. Photo: AJP

Communication between the pharmacist, prescriber and aged care staff is a high-risk area for medication errors, says Webstercare’s Gerard Stevens

On Tuesday AJP looked at a study by Monash University researchers recently published in the Journal of the American Geriatrics Society.

The systematic review of 11 international studies published between 2000 and 2015 found:

  • Medication errors were common, involving 16-27% of residents regarding all types of medication errors;
  • Transfer-related medication errors occurred in 13-31% of residents;
  • 75% of residents were prescribed at least one potentially inappropriate medication (PIM); and,
  • Serious impacts were surprisingly low, reported in only 0-1% of medication errors with death being a rare event.

While clinical consultant pharmacist Debbie Rigby responded that the results did not surprise her, Webstercare Managing Director Gerard Stevens has told AJP that the results are “alarming”.

“These are alarming statistics and not consistent with my experience as a pharmacy owner who attends a lot of Medication Advisory Committee meetings in aged care homes,” says Stevens.

He says the risk of harm to the resident depends on what is considered as a medication error.

“In my experience, aged care homes may report a serious medication error where a resident has been harmed by receiv[ing] the wrong medication and at the same time also report a nurse failing to record a signature on a medication chart for a medication that had been administered as an error.

“This is driven by the accreditation process in Australia where there is an emphasis on transparency and the actions taken to reduce the potential for harm are where the focus lies,” he explains.

Stevens believes improved communication using printed information and electronic records can help to reduce the risks of errors in aged care environments.

“Communication between the pharmacist, prescriber and aged care staff is a high-risk area for medication errors. If a pharmacist is not informed of a new medication or a dose change then that might be an error.

“Aged care homes that are using printed information on their medication charts and electronic communication to the pharmacist reduce the risk of errors in communication. The prescriber also has access to a complete medication profile at the time a decision is made to prescribe or change a medication.

“Access to legible and accurate information will reduce the risk of medication errors. In my experience in my pharmacy, we probably spend 60% of our time on medication reconciliation. That means making sure our information is complete and accurate before we pack,” says Stevens.

Regarding the prescription of inappropriate medications, he says each resident must be treated as an individual and a risk-benefit analysis conducted on a case-by-case basis.

“This is the underlying principle behind pharmacists conducting medication reviews and providing education for aged care staff,” says Stevens.

“There is a fine line between the potential of medications to do harm or to be of benefit. The fact that the level of serious impact is so low demonstrates that Australian pharmacists are walking this line and doing it incredibly well. When we as a profession make decisions on behalf of frail elderly residents we must make sure they are made in their best interest.”

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