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Medication Errors in Aged Care Facilities

Medication Errors in Aged Care Facilities


INTRODUCTION

Medication-related problems are most commonly reported in elderly patients (Roughead, Semple & Gilbert, 2003). As studies and investigations continue in the area of elderly care, increasing evidence suggests the need for increased research and support is needed in elderly medication management. In 1991, Roughead et al (2003) report that Australia's services supporting the quality use of medicines for aged-care facilities was highly limited. By 2002, Australia's range of services expanded and now includes government funded medication review services of which about 80 percent of all residents are recipients of the service (2003). With the increasing changes in health care services, there remains one consistent concern, the level of health care given and care in administering medications to the elderly. Understanding the limits on authority and the workload placed on health care facilities' staff, specifically nurses, will equip local and national agencies in addressing such issues as medication errors.


Points of Concern

Elderly patients in Australia rank highest in reported medication errors. With reported incidents of lack of care provided by facilities (Lumby, 2001) patients should not have to worry about incidents of medication error. The purpose of this study is to provide factual data that support the growing concern of medication error in elder care facilities, addressing reasons for such error.

In 2001, Lumby (p. ix) told the story of "Sue", an Australian patient recently diagnosed with a life-threatening illness (primary biliary cirrhosis, a progressive disease of unknown aetiology). According to Lumby, the subsequent medical directive following her initial diagnosis was to "go home and get on with life—put all of this behind you" to which she told Lumby, "I have just been told to go home and live until I die". As Lumby asserts, this story embodies so much of the best and worst aspects of the Australian health care system today [2001]. Contrary to this scenario, the general issues of medication error can most often be credited to other factors versus that of simply uncaring medical personnel. In fact, the most common factor involved in medication error is believed to be illegible documentation in charts/physician orders.

In a case study of Raymond Terrace Gardens Nursing Center, the administrative staff found that electronic prescribing drastically reduced its error ratio, which was attributed primarily to "problems plaguing handwritten medication charts, primarily due to problems of legibility" (Electronic Prescribing, 2005). According to the study conducted by the Australian Government Department of Health and Ageing (Dec. 2005), general practitioners (GPs) can electronically generate accurate medication charts and provide prescriptions to the pharmacy that are clear and easy to read (Electronic Prescribing, 2005, p. 1). Results of the study also reveal that the Center's nursing staff liked the system because the medication sheets were legible and clear (1). Other benefits include the improved legibility of scripts improved that directly resulted in "less opportunity for medication errors" (1). A quick reference and cross-check was available for GPs to "check for medication interactions, store information on allergies and receive alerts to contraindications" (1).


Factual Data

In June1982, Barker, Mikeal, et al reported on medication errors in elder care facitilies and hospitals. According to their study (1982:987-91), analysts used an "observation method for measuring the rate of medication errors" that provided an indication of various medication systems' quality. The analysis was conducted over a three-hour period, during which time "trained nurse and pharmacist observers observed nurses administer medications during the peak medication workload" (1982).

Following the observation, Barker et al (1982) note findings as follows:
The mean-medication-error rate was 12.2 and 11.0% in the LTCFs and hospitals studied, respectively.
Three LTCFs and four hospitals had error rates of zero.
Only 31% of the LTCFs and 40% of the hospitals would pass a medication-error limit standard of 6%. (Barker, et al, 1982)

Concluding statements asserted that the observation method used was "promising" and recommendations followed. Such changes recommended include the "implementation of a one-year project to evaluate observer efficiency after becoming proficient with the method, improvement of the reliability measure, and examination of the relationship of medication errors with structure and process variables" (1982:989-91).

According to Australian Pharmaceutical Advisory Council (APAC) Guidelines (2002:1), the elderly are recognized as the largest users of medications. Medication management in residential aged care facilities and the appropriate understanding and application of management procedures continue to be a major concern of governing entities and individual facility administrators. Clearly, as reiterated in the Guidelines (2002), medicine has the potential to make a "significant contribution to the treatment and prevention of disease, increasing life expectancy and improving quality of life" and the potential to cause harm (Guidelines, p. 1).

While illegible charting has been referenced, other factors contribute to medication errors, including exhausted staff (working double shifts, etc.) poor training (has not acquired sufficient knowledge to understand medication contraindications), difficulties accessing GPs for new and existing residents (e.g. see Electronic Prescribing, Case Study 2, 2005), and misunderstood or incorrect preparation and distribution of policy and procedure guidelines, among others.

While a common problem in health care settings, illegible handwriting is not the only contributing factor in prescription errors. In fact, problems may exist with the prescription itself, whereby thorough checks for drug allergies and interactions between medications should be conducted, with information readily available and easily accessed, to insure that the prescription is the correct one. The quality of communication between GPs and other staff enables the collective group to perform better for the patient. When communication fails in one or more areas, risks are taken and errors often occur.

In a International Journal for Quality in Health Care journal report, Runciman, Roughead, et al (2003:i49-i59) concerning adverse drug effects and medication errors, report findings conclude that in a complete review of medical records, 2 to 4 percent (about 30 percent for patients over 75 years of age) of all hospital admissions errors are medication-related and about three-quarters are potentially preventable. Routine data collections, including death certificate and hospital discharge data coded using the International Classification of Diseases capture less than half as many adverse drug events (ADEs) as medical record reviews (Byles et al, i50) (Byles, Heinze, et al, 2003). Out of all coded adverse events that contributed to death, 27 percent involved an ADE, including about 20 percent of adverse events identified at discharge and 43 percent at general practice encounters (i50). The authors (2003) indicate "there is a strong correlation between increases in medication use and rates of adverse drug reactions (ADRs) associated with hospitalization" (Byles et al, 2003: i49-i59).

In studies concerning drug implemented errors, similarities in all findings included anticoagulants, anti-inflammatory drugs, opioids, anti­neoplastics, antihypertensives, antibiotics, cardiac glycosides, diuretics, hypoglycemic agents, steroids, hypnotics, anticonvulsants, and antipsychotics (Byles et al, 2003:i49-i59). Clinical indicators show that an ADE is reported in 1 percent of all hospital admissions. However, not all patients report problems, thereby giving allowance to assume that percentage could be somewhat greater. In drug implemented errors, studies also indicate that only three-quarters of patients with acute myocardial infarction receive thrombolytics within one hour of symptom presentation and only about five percent of patients on warfarin record an international normalized ratio greater than five. An average of one percent, 0.05 percent, and 0.2 percent suffer abnormal bleeding, cerebral hemorrhage, or death, respectively (Byles et al, 2003:i49-i59).

According to reports using the Australian Incident Monitoring System, about 26 per cent of 27,000 hospital-related incidents were medication-related, including 36 percent of 2,000 anesthesia-related incidents and 50 percent of 2,500 general practice incidents (2003:i49-i59). In all cases studied, the greatest incidents of medication error were present in cases where ward stock medications were used (noted at about 15 to 20 percent of all drug administrations) (2003:i49-i59) (Byles, 2003). However, when using individual patient systems, the incident level decreased to about 5 to 8 percent. Sadly, in all areas studied, about 75 percent of patient charts lacked notation on previous allergic reactions to drugs (i56-i59).

Additionally, studies indicate an increased error ratio among elderly patients who are transferred to another facility. The process of charting and the change of GPs and other staff all change. When previous interactions with medications are not noted, the chances of serious error and risk to the life of the patient are imminent.


Regulations

In order to facilitate the quality use of medicines, each nursing home should establish, or have access to, a committee that is the responsible body for considering all aspects of medication use in the nursing home (NSW Department of Health Information Bulletin, 2003/10). By proper medication management or quality use of medicines regulatory committees define proper actions as those that include a "consideration of the appropriateness of the medication prescribed, the correct dispensing and administration, and the provision of appropriate information" (NSW, 2003).

Under the Poisons and Therapeutic Good Act (1966), medications marked as prescription only may only be obtained on the prescription of a medical practitioner, dispensed and labeled by a pharmacist for that individual resident [Section 10 (4) (c)]. When errors occur, investigating officials first look to determine who ordered the prescription, followed by who administered the medication. According to NSW Guidelines (2003):

In the interests of residents' safety, it is essential that pharmacists supply medications to individual residents only on the basis of written prescriptions or direct communication by telephone with prescribers. There is no provision for pharmacists to dispense medication for individual residents on the order of a nurse or other staff member, whether this is by telephoned requests or prepared lists, unless the pharmacist holds a current prescription for that resident's medication. (2003/10:3)

Nurses have authority to order and administer specific medications under specific situations (e.g. emergency situations). According to Clauses 102, 103, P & TG of Regulation 2002, the chief nurse of a nursing home is allowed to hold an "emergency stock of morphine and pethidine provided it is used only for the emergency treatment of residents on the authority of a medical practitioner". Furthermore, the Regulations (2002) imposed restrictions concerning emergency stock, asserting that such stock "must not exceed 5 ampoules of morphine sulfate containing 30mg or less per ampoule; and 5 ampoules of pethidine containing 100mg or less per ampoule" (2002).

When charting regulations are followed, discovering the origin of error is relatively easy. Regulations (2002) mandate medication charting procedures, citing that the record must show:
The date of entry
The time of day entry was made
The resident's name
The name of the drug
The amount administered with the amount recorded in the appropriate column
The amount of medication discarded (e.g., in the case of only part of an ampoule or tablet being administered to a resident (see Regulation 6.1.2), also recorded in the appropriate column
The amount of a specific medication received (e.g., receipt of drugs from a pharmacy). The entry here should reflect: Received from…….Pharmacy and the amount recorded in the appropriate column.
The amount destroyed (e.g., medication has become unwanted (see Regulation 6.2) and recorded in the appropriate column.
The balance of the medication remaining. Entries must detail that a balance check has been done. Charting will indicate the balance on hand and the actual balance.
Person making the entry must sign.
There must be a witness signature (6.1.2).
The name of the prescriber must be noted.

When all levels of entry requirements are followed, investigating errors is easier. In fact, when seeking specific information, investigators will quickly find the data and be able to compare to other records. Additionally, regularly scheduled audits work to reduce medication error instances. Other beneficial procedures include the rapidly increasing use of technology and information systems (information management) to maintain medical records and inventories.

Information Management has become one of the leading tools in medical facilities, particularly in the elderly care setting. IM works to give administrators and additional staff an accurate method of implementing of chronic disease initiatives (Medication Management in the Aged Care GP Panels Initiative (2003). IM tools include the ability to obtain specific information through category searches, including such tools as "age, sex, disease registers, recall and reminder systems, electronic form templates and health care plans" (2003).

Human error in any setting is inevitable; however, the instances of error are more devastating, it seems, in the health care industry. Patient and their family entrust their lives with men and women who have trained to understand the issues going on with their individual illnesses, care, treatment, and even in medical charting. Ongoing improvement is needed regardless of the ratio of medication errors reported. In fact, consistent evaluation of current charting and administering practices work to enhance the overall system of the facility while increasing the level of care given to the patient and the safety measures taken to ensure such safety is imminent.


Potential Regulation Reform

As the needs for services for the elderly rises, the need for changes in elder care policies must also be addressed. While regulations require that such facilities must have a drug committee that is responsible for considering all aspects of medication handling within the service. According to federal guidelines, the committee should include "representation from each of the three following disciplines: pharmacy, medical and nursing" (2003) with consideration to that of the facility's management staff. Such functions of the Committee must include the "development and approval of written medication policies and procedures (including the design of medication charts), the rationalization of drug use in relation to efficacy, safety and cost, the analysis of medication incident reports, and any recommendations concerning the on-going education of staff" (2003).

When patients enter a hospital or other treatment or care facility, they reasonably assume that the treatments and care received will make them better, or, at the least, not make them worse. However, when the factor of human interaction is considered, specifically the interaction between patients and nurses, doctors, pharmacists, technicians, and others, each individual encounter presents an opportunity for error. And, yes, errors inevitably occur. Even those professionals trained to avoid error at all costs (e.g., doctors, nurses, and pharmacists) sometimes make mistakes. Sometimes those mistakes cause injuries and, sadly, even death in some cases.

With the ongoing reform issues surrounding health care regulation, the chances of medication errors will decrease. However, the chances of error are always going to be a part of any industry, they are only more devastating and obvious when such errors occur in the health care setting as lives are put in danger.


CONCLUSION

Medication-related problems are most commonly reported in elderly patients with the most common error factor being that of charting complications (e.g., illegible notes, etc.) (Roughead et al, 2003:i49-i59). In the face of a world of technological advancements and the availability of technological recording programs, such errors can be avoided and the number of reported incidents of medication errors significantly reduced.

As studies and investigations continue in the area of elderly care, increasing evidence suggests the need for increased research and support is needed in elderly medication management. In 1991, Roughead et al (2003) reported that Australia's services supporting the quality use of medicines for aged-care facilities was highly limited. By 2002, Australia's range of services expanded and now includes government funded medication review services of which about 80 percent of all residents are recipients of the service (2003). With the increasing changes in health care services, there remains one consistent concern, the level of health care given and care in administering medications to the elderly. Understanding the limits on authority and the workload placed on health care facilities' staff, specifically nurses, will equip local and national agencies in addressing such issues as medication errors.

As most in the industry understand adverse drug effects (ADEs) are the most common of all incidents within the Australian health system. In all cases where medication errors occurred, more than half were involving anticoagulant, anti-inflammatory, and cardiovascular drugs. Although changes have been made and improvements suggested and implemented, the methods for monitoring and preventing ADEs should be progressively enhanced.

Understanding the differences between clear human error and preventable incidents is important. As explained within this document, human error in any setting is inevitable; however, the instances of error are more devastating, it seems, in the health care industry. Patient and their family entrust their lives with men and women who have trained to understand the issues going on with their individual illnesses, care, treatment, and even in medical charting. To reiterate, ongoing improvement is needed regardless of the ratio of medication errors reported. In fact, consistent evaluation of current charting and administering practices work to enhance the overall system of the facility while increasing the level of care given to the patient and the safety measures taken to ensure such safety is imminent.


Definitions
ADE – adverse drug effect
ADR – adverse drug reaction
GP – general practitioner
LTCF – long term care facility






References:
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Posted by: Sancha Haysbert

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