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Tariq, Amina, Georgiou, Andrew, Raban, Magdalena, Baysari, Melissa, &Westbrook, Johanna(2016)Underlying risk factors for prescribing errors in long-term aged care: aqualitative study.BMJ Quality and Safety, 25(9), pp. 704-715.

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https://doi.org/10.1136/bmjqs-2015-004589

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Title: Underlying risk factors for prescribing errors in long term aged

care: A qualitative study

Amina Tariq1, Andrew Georgiou1, Magdalena Z Raban1, Melissa Baysari1, 2, Johanna

Westbrook1

1 Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Australia

2 Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Sydney Australia

Correspondence should be addressed to Amina Tariq at the Centre for Health

Systems and Safety Research, Australian Institute of Health Innovation, Level 6 75

Talavera Road, Macquarie University NSW 2109, Australia. Tel: +61 (0)2 9850 2481.

Fax: +61 (0)2 8088 6234. (email: amina.tariq@mq.edu.au)

WORD COUNT: 4700 words (excluding abstract, tables and references)

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Abstract

Objective(s)

To identify system-related risk factors perceived to contribute to prescribing errors in

Australian long term care settings i.e. residential aged care facilities (RACFs).

Design and Setting

The study used qualitative methods to explore factors that contribute to unsafe prescribing in

RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May

and November 2011. Participants included RACF managers, doctors, pharmacists and RACF

staff actively involved in prescribing-related processes. Methods included non-participant

observations (74 hours), in depth semi-structured interviews (n=25) and artefact analysis.

Detailed process activity models were developed for observed prescribing episodes

supplemented by triangulated analysis using content analysis methods.

Results

System-related factors perceived to increase the risk of prescribing errors in RACFs were

classified into three overarching themes: communication systems, team coordination and staff

management. Factors associated with communication systems included limited point of care

access to information, inadequate handovers, information storage across different media

(paper, electronic and memory), poor legibility of charts, information double handling, multiple

faxing of medication charts and reliance on manual chart reviews. Team factors included lack

of established lines of responsibility, inadequate team communication and limited participation

of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors

related to staff management and workload included doctors’ time constraints and their

accessibility, lack of trained RACF staff and high RACF staff turnover.

Conclusion

The study highlights several system-related factors including laborious methods for

exchanging medication information, which often act together to contribute to prescribing

errors. Multiple interventions (e.g. technology systems, team communication protocols) are

required to support the collaborative nature of RACF prescribing.

Key words: long term care, residential aged care facilities, prescribing,

communication, system errors, medication errors

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Introduction

Concerns about prescribing safety in long-term aged care facilities have been raised

worldwide by policy makers, academic researchers, the media and residents’ families.1-12

To

reduce preventable harm, safe prescribing in aged care facilities requires consideration of

residents' total needs in order to mitigate cognitive and functional deterioration.1-3

Various

studies exploring prescribing safety in long-term aged care facilities report a higher rate of

prescribing errors compared to hospitals.7, 14, 15

Australian long-term aged care facilities also

report a high incidence of polypharmacy with residents averaging seven to ten medications

each.16, 17

One US study found 40% of long term care residents regularly received at least

one inappropriate medicine,18

and in another study, 17% of residents had daily doses of

antipsychotic drugs exceeding recommended levels.19

In Australia, long-term aged care facilities which provide personal as well as nursing care for

residents are known as residential aged care facilities (RACFs). In RACFs, safe medication

delivery is reliant upon the coordination of activities across three key domains: i) general

practitioners (GPs), who practice offsite but are responsible for prescribing; ii) community

pharmacies, where medications are dispensed and packed into unit dose blister packs; and

iii) RACFs, where medications are administered.20

In addition to these three domains, RACFs

need to coordinate with hospitals, medical specialists and allied health staff who also provide

services to residents on a regular basis.21

Human errors in such dispersed and dynamic

contexts are described as a property of the system as a whole, rather than an individual’s

responsibility.22-24

Individuals might initially appear responsible for errors; however,

investigation into these errors usually uncovers a wide range of system-related factors that

contribute to the error.25, 26

Designing or implementing interventions that are effective in improving prescribing safety

requires identification and consideration of the system-related factors that contribute to

medication error occurrence.29-31

Existing medication incident reporting systems in RACFs are

poorly designed and focus on individual responsibility for errors.32

They have limited capacity

to improve safety because they only identify factors that are proximal to the incident.32

While a

single action or omission by a GP may appear as the immediate cause of a prescribing error,

investigations often ignore the latent weaknesses in the working environment that promote or

permit errors.25, 33

A systems approach recognises that the likelihood of an unsafe act is

influenced by the nature of the task and local working conditions.33, 34

Few studies have examined prescribing errors in long term aged care settings and fewer still

have investigated potential causes of these errors.15, 27,28

Barber et al.,15

prospectively

analysed errors and their potential causes across different stages of medication management

in UK aged care homes, and identified communication(written and verbal), between the

nursing home, GPs and pharmacy as a major contributor to medication errors. In 2008, a

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broad review of 40 studies exploring the incidence and types of medication errors in aged

care settings reported that despite widespread recognition of the potential role of system-

related factors in increasing the risk of medication errors, little attempt had been made to

identify these system-related factors.27

In this qualitative study, we aimed to conduct an in-

depth examination of RACF prescribing processes to identify specific system-related factors

perceived to contribute to prescribing error risk in RACFs and pinpoint interventions that could

potentially reduce that risk.

Materials and Methods

Setting

The context of this research is RACFs in Australia, which provide accommodation, nursing

care, domestic services (such as laundry, meals and cleaning) and support for personal tasks

(activities of daily living) for residents.4 Prescribing errors in health care settings are generally

defined as “…a prescribing decision or prescription writing process, [where] there is an

unintentional significant (1) reduction in the probability of treatment being timely and effective

or (2) increase in the risk of harm when compared with generally accepted practice”.13

(p. 235)

A convenience sample of three RACFs in metropolitan Sydney, Australia participated in the

study. The selected sites were part of a large non-profit organisation. Participating sites had

populations comprised of a mix of residents classified as either: a) low-level care that covered

the provision of suitable accommodation and related living services (such as cleaning, laundry

and meals), as well as personal care services (such as help with dressing, eating,

medications and toileting); and b) high-level care that covered accommodation and related

living services, personal care, nursing care and palliative care. The RACF care staff members

are required to achieve competencies (as per the established organisational criteria) to

become eligible to administer medications. At the organisational headquarters, the quality

management team is responsible for monitoring the quality of the care services provided by

the facilities. The quality manager is supported by a qualified team including a registered

nurse (RN) as well as an administrative assistant who organises and manages information.

GPs prescribe on residents’ paper medication charts maintained at the RACFs for medication

administration (Figure 1). In addition, they are required by legislation to provide separate

prescription for every medication to allow dispensing by community pharmacies. The chart

contains different sections for prescribing regular medications; short-term medications (e.g.

antibiotics), PRN (pro re nata (when required)) and non-packed medications (e.g. eye drops).

GPs are required to rewrite the whole chart every six months. The charts are faxed to the

community pharmacies along with the prescriptions for every new medication order, altered

orders or discontinuations.

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Figure 1: A Resident's Medication Chart

Participant Recruitment

The study participants were purposively recruited, based on their involvement in medication

management processes at the sites. Ethics approval was obtained by the University of New

South Wales, Sydney, Australia. Table 1 presents the details of the sites and participants.

Informed written consent was obtained from all study participants prior to data collection.

Data Collection

Data were collected using direct observations and semi-structured interviews supplemented

with detailed artefact analysis to obtain context-rich information. Direct observations within

RACFs were conducted of all activities related to prescribing (e.g. verbal communication,

GPs’ reviewing residents’ information and prescribing). Prescribing-related activities that

occur outside RACFs were not included. One of the authors (AT) collected observational data

over seven months. The observer was a trained human factors analyst with extensive

experience in conducting qualitative research.

Field notes and photographs of the artefacts were a prime source of data. Artefacts in this

study encompassed “any artificial device designed to maintain, display, or operate upon

information in order to serve a representational function”.35

(p.17) All the key artefacts used in

the prescribing process, namely medication charts, discharge summaries, doctors’ notes and

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electronic progress notes were analysed to determine their content, physical form,

representations used (e.g. abbreviations) and inter-dependencies (e.g. both medication charts

and residents’ medical notes to be updated to reflect the actual change in medication and

reasons for the change, respectively).

Observations were conducted during day shifts (7:00-15:00) on weekdays, as site managers

indicated that doctors’ visits and prescribing-related activities are most intense during these

times. During observations, participants were asked specific questions to clarify information

about the activities performed and the related use of artefacts. These short-duration

purposive field interviews were distinguishable from the detailed semi-structured interviews in

that they were conducted in the immediate context of the activities being performed. These

interviews were undertaken opportunistically rather than by prior agreement and were

transcribed into the field notes. One of the researchers (AT) also attended two medication

advisory committee (MAC) meetings. These bimonthly meetings aimed to provide a platform

for GPs, pharmacists and RACF managers to discuss medication management issues.

RACFs (usually up to five sites) were grouped together based on their location and sharing of

services from the same community pharmacy. The MAC meetings were scheduled at one of

the RACF sites included in the group, for a duration of one to two hours during working hours.

To gain an understanding of the issues raised in MAC meetings, minutes of the last five

meetings held for the study sites were also reviewed.

As the prescribing process components were distributed over time and space; it was not

possible to capture the complete process by using observations alone. Semi-structured

interviews enabled identification of system-related factors perceived by the participants to

contribute to error occurrence. Interviews were conducted at the RACFs (Table 1). The

interview guide was informed by literature suggesting approaches to examination of system

factors in health care settings.24-26

A pilot interview with one RACF manager and a pilot two

hour observation session at one site prior to data collection were conducted. The participants

were asked questions on a range of issues relating to RACF prescribing processes, including

examples of common prescribing errors, information exchange, artefacts, and coordination

with other professionals involved in the process. They were prompted to discuss any issues

they experienced during the prescribing processes. Selected members of the organisation’s

quality management team were also interviewed to gain an understanding of quality concerns

relating to prescribing processes. All interviews were audio-taped, professionally transcribed

and verified.

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Table 1: Data Collection Summary

Residential aged care facility - Site A

Site Characteristics

Number of residents: 58 (low care=30, high care=18)*

Staff distribution:1 care manager (also the nursing consultant), 1 deputy care manager, 8 personal care workers, 8 staff members (qualified for medication administration)

Number of doctors: 6 †

Number of servicing pharmacies: 2

Observations

Sample: 3 doctors, 1 care manager, 1 deputy care manager, 7 staff members, 1 pharmacist, 1 pharmacy technician

Total observation time: 28 hours (prescribing episodes=9) ‡

Average observation time per session: 4.5 hours

Interviews

Sample: 1 doctor, 1 care manager, 1 deputy care manager, 3 staff members

Average time per interview: 25 minutes

Residential aged care facility - Site B

Site Characteristics

Number of residents: 46 (low care only) Staff distribution: 1 care manager, 1 deputy care manager, 1 nursing consultant (part-time), 6 personal care workers, 8 staff members (qualified for medication administration)

Number of doctors: 5†

Number of servicing pharmacies: 1

Observations

Sample: 4 doctors, 1 care manager, 1 deputy care manager, 1 nursing consultant, 8 staff members, 1 pharmacist Total observation time: 26 hours (prescribing episodes=8) Average observation time per session: 4 hours

Interviews

Sample: 1 care manager, 1 deputy care manager, 1 nursing consultant, 3 staff members Average time per interview: 29 minutes

Residential aged care facility - Site C

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Site Characteristics

Number of residents: 26 (low care only) Staff distribution: 1 care manager, 1 deputy care manager, 1 nursing consultant (part-time), 5 personal carer workers ,4 staff members (qualified for medication administration) Number of doctors: 4 Number of servicing pharmacies: 1

Observations

Sample: 2 doctors, 1 care manager, 1 deputy care manager, 1 nursing consultant, 4 staff members, 1 pharmacist Total observation time: 20 hours (prescribing episodes= 6) Average observation time per session: 4.5 hours

Interviews

Sample: 1 deputy care manager, 1 nursing consultant (also serves site B), 2 staff members

Average time per interview: 25 minutes

Quality Management Team at Headquarters

Interviews

Sample: 1 quality manager, 2 members of the quality management team Average time per interview: 35 minutes

* Low-level care covered the provision of suitable accommodation and related living services as well as personal care services. High-level care covered accommodation and related living services, personal care, nursing care and palliative care.

† Visiting on a regular basis ‡ A prescribing episode was the time during an observation session where a doctor visited the RACF site and added or discontinued medications, wrote prescriptions or renewed medication charts for one or more residents

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Data Analysis

The data collected consisted of detailed information on the activities performed as part of the

RACF prescribing processes. To facilitate in-depth examination, analysis was undertaken by

initially synthesising the qualitative data to develop maps of observed prescribing scenarios

using the business process model and notation (example scenarios presented in Figure 2 and

3).36

These process maps enabled the: 1) Detection of common patterns of prescribing

related activity across different scenarios, and 2) Identification of inter-linked issues involving

tasks, people and artefacts. The examination of artefacts used during prescribing provided

insight into the artefacts’ context and purpose. Further, we used triangulated content analysis

to derive themes relating to system-related factors underlying errors.37

NVivo software was

used to support qualitative analysis.38

The interview guide was employed in the initial stage of

analysis to form broad, macro-codes and a taxonomy of system-related factors under which

open-coded content could be classified. One author performed the initial open coding of the

data, which was reviewed and modified by the research team. Data were iteratively analysed

in research team meetings (n=10). Revision and finalisation of themes was achieved by

consensus. Member checking of results occurred through follow-up interviews with

participants. A focus group with participants (quality manager, site managers and the nursing

consultant) was conducted at one of the study sites to review the process maps and findings

from the observational data.

Results

We conducted a total of 74 hours of observation (average observation session 4-4.5 hours)

across three sites between May and November 2011. During these sessions we observed 23

unique prescribing episodes. (i.e. where a doctor visited the RACF site and added or

discontinued medications, wrote prescriptions or renewed medication charts for one or more

residents). We interviewed 25 participants, including RACF managers, nursing consultants,

RACF staff members involved in prescribing related activities and doctors. The observations

and interviews were conducted until theoretical saturation was reached, a point at which we

were no longer gaining new information from subsequent participants.

Prescribing errors and associated themes

Table 2 presents examples of different types of prescribing errors described by the

participants during interviews. Errors included omission of a regular medicine, incorrect or

missing dosage details and mismatches between a medication order on the chart and the

associated prescription. The triangulated analysis produced three over-arching themes, with

contributing sub-themes, describing system-related factors related to the occurrence of

prescribing errors. The most prevailing theme was communication systems. This theme

reflected the effectiveness of systems in place to allow the exchange of information between

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GPs, RACF staff, community pharmacists and hospitals. This included both written and verbal

communication. The second theme related to how each of the different professionals (GPs,

RACF staff and pharmacists) worked as part of a team. The final theme encapsulated the

factors associated with appropriate management of staff and workload issues in relation to

medication management. We noted interactions between the thematic categories, such as

communication and staff management factors (Table 2). Participants often cited multiple

factors that contributed to the occurrence of a single error. For example, as discussed below,

the case of an omission of Parkinson’s drugs for one of the residents was associated with

both communication system factors and team factors.

Table 2: Examples of prescribing errors Example Prescribing Errors

We also had a case a little while ago where the doctor re-wrote the chart and left off a lady’s Parkinson drugs...it wasn’t picked up for a couple of days and when you actually looked at the chart and you looked at the medication pack, they matched. The fact that he left off the drugs we would never have picked up until the lady of course began to get some difficulty with her walking”(Interview- Quality Team Member)

“The Gastrogel [prescribed by doctor], doctor has put ten to twenty mg, we would never have ten to twenty milligrams, it’s either ten or twenty [be]cause our care staff can’t make a clinical decision… We never have variable doses in this [be]cause it’s ultimately then the pharmacist who’s choosing to pack it” (Interview - Care Manager, site C)

“He obviously just hasn’t written the alternate [days] Or like written three times a week [on a renewed chart]. Which does happen? Sometimes when they’re [doctors] in a hurry” (Interview - Care Manager, site A)

“Doctor might order something on the medication chart and then he may say something different, perhaps he might say for instance have it once a day and then [on] the medication chart he might say twice a day”(Interview- Care Manager, site B)

“Doctor has put seventeenth to the twenty-fourth [for the first course of antibiotics] but then twenty-fourth to the first so it could end on the twenty-third then the twenty-fourth [for the second course of antibiotics]...I prepare the signing sheets by putting dates on it as the girls will – they’ll get these two orders [at the same time] which are of different doses” (Interview - Deputy Care Manager, site B)

“Sometimes the script doesn’t match the chart for lots of reasons because doctors forget or they write one thing on our chart and something else on the script”(Interview - Quality Manager)

“What’s interesting about this [a resident’s medication chart] is there’s no doctor’s signature so that’s actually a legal thing so I’d be actually saying who gave it and where’s the doctor’s signature?” (Interview - quality team member)

Theme 1 - Communication system factors

Our findings revealed that existing communication systems made prescribing a cumbersome

process. GPs often found it difficult to access a resident’s background information at the point

of care. As depicted by the scenario in Figure 2, the information for prescribing decisions was

distributed across different artefacts (e.g. medication charts, progress notes etc.) and storage

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media (paper, electronic and individual’s memory). The accuracy, relevance, completeness

and timeliness of the information during prescribing relied heavily on manual procedures.

Hospital discharge letters were often unclear and incomplete. Figure 3 illustrates a situation

where a GP ceased a medication on which a resident was discharged from hospital. The

discharge summary did not list the reason for prescribing the medication and the GP had to

make a decision based on his/her experience with the resident.

When not in attendance at the RACF, GPs relied on RACF staff to give them all the required

information verbally on the telephone.

“When you talk to doctors [on telephone] they naturally don’t have sort of access – they don’t have

access to the information so you give them updates on some of that – because they don’t have

medication charts or things in front of them” (Interview - nursing consultant)

Interviews with the RACF staff identified that the nature of this information exchange varied by

staff or shift. For instance, it was reported that during night shifts, managers were absent and

the accuracy and quality of information provided could be incomplete. As indicated by the

scenario in Figure 2, GPs complained about RACF staff contacting them or requiring urgent

visits, yet subsequently being unable to explain why they had been called.

Analysis identified poor legibility of the medication chart as a major communication issue.

“Doctor [X] been in to see [the resident] and put him on a course of prednisone and often you can’t

read the writing. I’ve got used to it but it’s still hard” (Interview - deputy care manager, site A)

“It’s like insulin now they have to write the units. You can’t just put 8u’s because sometimes

people’s u’s look like zeros so they have to write 8 units, U N I T S” (Interview - nursing consultant,

after prescribing episode)

Artefact analysis revealed that the medication charts often exceeded 4-5 pages with

numerous changes and omissions. GPs frequently needed to renew charts which required

them to review and rewrite the complete list of medications. Participants reported that this

often resulted in errors, such as omissions (Table 2).For offsite prescribing activities (e.g.

correction of a resident’s chart), the exchange of information relied on faxing residents’

medication charts between the GP and RACFs.

“If doctor has done a mistake in writing the medication chart and they cannot come to fix it I fax

them the medication chart to get it corrected. They fax it back to us and I paste this chart in the

medication charts folder and next time doctor comes in they can write on the original chart and we

can then remove the fax copy” (Interview - deputy care manager, site C)

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The exchange of residents’ medication charts using a fax was also a common practice in

scenarios which required doctors to prescribe medications (e.g. antibiotics) when offsite. This

resulted in the cluttering of medication charts with scribbles and multiple fax pages with no

page numbers stapled to residents’ medication charts.

“If something happens, say for argument’s sake I’m a nurse and I could ring up a doctor and say,

look [resident X] looks like she’s got cellulitis or her wound looks infected, they might say look I’ll

put them on a course of antibiotics, I would fax chart over to them and they would then write it, fax

it back and then I would actually have to stick it in there. So that sometimes you will see that the

charts have stuck in pages.” (Interview - quality team member)

Double handling of information was visible throughout the process. GPs were required to

document notes in residents’ files as well as maintain their own notes.

“They [doctors] have their own files in the surgery and they update those when they visit here. Well

you would hope that they would do” (Interview - nursing consultant)

Writing medication orders on the chart as well as the paper prescriptions for the community

pharmacy resulted in inaccuracies due to mismatch of information between the two.

“I’ve actually contacted the doctor [using the telephone] in regards to that prescription; it is different

than what medication chart says so needed to confirm which one is correct” (Interview - deputy

manager, site B)

Chart auditing was infrequent due to the time and resources required. This made it difficult for

community pharmacies and doctors to verify and correct discrepancies in a timely manner

and errors may result because of the mismatch between charts and medication packs.

“Three years ago it was, [quality team manager] and I physically actually audited twelve hundred

charts. We did medication audits for days and days and days... sometimes there were things in the

[medication] pack that weren’t on the chart or things in the chart that weren’t in the pack” (Interview

- quality team member)

Theme 2 – Team coordination factors

Factors associated with team coordination included dispersion of responsibility, inadequate

team communication and failure of GPs to attend MAC meetings. The responsibility for safe

medication management in RACFs was distributed between GPs, pharmacists and RACFs.

Although the different stages of the medication process (prescribing, ordering, dispensing

etc.) were linked, each stage was carried out in isolation from the other. GPs prescribed

without direct contact with pharmacy, and without being present to observe the consequences

of the medication administration. Individuals attempted to do their best, but in an

13 | P a g e

uncoordinated way and without appropriate understanding of the constraints of the system as

a whole.

“The fact that he [doctor] left off the drugs we would never have picked up until the lady of course

began to get some difficulty with her walking, which is what happened. But in that case the GP

said that’s your [RACF’s] problem. Well it’s not our problem because you’re [GP] responsible for

filling out this chart... The staff doesn’t have to check that you’ve done the right thing... Now the

pharmacist should have twigged, hey this person’s suddenly missing Parkinson’s drugs, how

come? But then as a pharmacist said to me, if we did that with every chart that came across our

desk, we would spend all day every day saying Doctor X did you mean to not do it. So it’s not

really the pharmacist’s responsibility either” (Interview - quality team member)

MAC meetings were identified as the only collaborative discussion forum which provided an

opportunity for RACF managers, community pharmacists and GPs to discuss issues related

to residents’ medications. GPs were absent in the observed MAC meetings, which inhibited

team level understanding of the demands and constraints faced by GPs during prescribing.

“MAC meeting usually it could be bimonthly or they could be monthly. Because you’re depending

on the GPs if they will come and a lot of times GPs won’t so depending on when the pharmacist

will come” (Interview - care manager, site A)

Further the RACFs had no formal procedure to record prescribing errors, which limited the

capacity of the team to collectively reflect and learn from errors.

“At the moment prescribing errors are not recorded formally. They are not part of the key quality

indicators (KQI)” (Interview - quality manager)

Theme 3 - Staff management factors

Factors associated with appropriate management of staff and workload also appeared to

increase the risk of prescribing errors. The services offered by GPs were variable as some

visited regularly while others visited only if requested or in cases of emergency.

“Some doctors will come only when they’re [residents] sick and that’s a bit painful” (Interview -

deputy care manager, site B)

Limited timely access to locum GP services including after-hours services was also identified

as a potential factor.

“They’re [locum doctors] contacted as they’re needed to be contacted and we do have an

after-hours service which can be accessed by phone only. There’s only a handful of them

14 | P a g e

really, most of them belong to [service provider X] and [service provider Y]”. (Interview-deputy

care manager site, C)

The requirement to proactively arrange locum doctors to cover for regular GPs when absent

for long periods of time was viewed as a barrier to seamless or uninterrupted prescribing

processes.

“Doctors are busy. And you can appreciate it but if they can’t do it, they need to let us know

they can’t do it. Or if they go on holidays for like three months to let us know. Otherwise there

is no one to relieve them… they [residents] need a contact or a covering doctor. So that’s

something that we’re working on” (Interview- nursing consultant, site B,C)

During observed prescribing episodes, GPs frequently mentioned time constraints. RACF

staff also identified inadequate access to GPs and short availability times as barriers to safe

prescribing.

“They’re busy, doctors not reliable, you keep calling, you [are] waiting for them and, they can

ring and say “Look I’m really busy, maybe another day?” (Interview - deputy care manager,

site C)

Both GPs and RACF managers mentioned limitations in staff skills and lack of knowledge to

support GPs during prescribing.

“Staff do not understand what I am saying to them or asking for” (GP to RACF manager

during prescribing)

“Some people [RACF staff members] may be illiterate and so – and again it’s their

comprehension of English and what do they understand..... Without that sort of underpinning

knowledge, it’s very difficult because they don’t understand why it’s important for someone

with Parkinson’s to have their drugs on time and what happens to them if they don’t”

(Interview - care manager, site A)

The participants also identified staff shortages in RACFs and high staff turnover as factors

that affected the execution of medication tasks.

“It’s a continuous education thing because you’ve always got new staff, [staff is] fairly mobile

so you find that you’ve always got new staff and you need to do their training and education”

(Interview - deputy care manager, site B)

15 | P a g e

A shortage of registered nurses (RNs) and delegation of medication tasks to carers was also

viewed to be a factor increasing dependence on GPs to ensure accuracy and completeness

of prescribing orders.

“It’s very difficult to get RNs to work in aged care so we use them to oversee the clinical stuff, we

want them to be looking at wounds and education and care planning and all those sorts of things”

(Interview - quality team member)

The shortage of RNs was also evident from one RN working as a nursing consultant across two

study sites, since the care managers at those sites were not RNs

16 | P a g e

Figure 2: Prescribing episode example 1- General Practitioner (GP) visits RACF following an urgent request to attend a resident from the RACF

17 | P a g e

Figure 3: Prescribing episode example 2- General Practitioner (GP) visits RACF to examine a resident discharged from hospital

Discussion

This study involved an in-depth examination of prescribing processes to identify latent

system- related factors identified as increasing the risk of prescribing errors in long term aged

care facilities. The identified system-related factors were classified into to three overarching

themes: communication systems, team coordination, and staff management. To collectively

address identified system-related factors, multifaceted strategies are required.

The most significant perceived risk factors were associated with communication systems. We

found that the antiquated prescribing processes in RACFs involving paper-based medication

records, double handling and faxing increased risk of prescribing errors. To address double

handling of medication charts and prescriptions, the Australian government has been piloting

a standardised national medication chart for RACFs since 2012.39

This chart will allow

dispensing for most medications, eliminating the need of prescriptions, therefore addressing

the risks associated with double handling. However, the new chart will not address the array

of other issues identified in this study which include legibility problems, offsite communication

with GPs and information transfer during transitions across different healthcare settings (e.g.

hospitals).38

Shared electronic medication records could enable GPs and community

pharmacists to remotely access residents’ records, offer electronic decision-support (e.g.

alerts on accidental omissions), incorporate mandatory data fields and reduce legibility

problems.40, 41

The implementation of the Australian national personally controlled electronic

health record is in its nascent stages and currently does not include a medication record.42

However future developments may enable shared medication information transfer.42

RACFs in Australia, when compared to health care settings (e.g. hospitals), are in the early

stages of adopting technology-based interventions to support medication management

processes.43, 44

This provides an opportunity to learn from the experiences of the

implementation of these interventions in health care settings, such as hospitals and GP

practices. Electronic medication management systems in Australian hospitals have been

shown to reduce prescribing errors by more than 50%.45

However, studies evaluating

implementation of technology interventions in health care organisations have shown that

failure to address the socio-technical requirements of these complex interventions increases

the likelihood of unintended consequences, encourages adoption of workarounds and

elevates risks to patient safety.46-48 The challenge in aged care is that a single organisation

providing aged care receives services from a number of GP practices, community pharmacies

and hospitals. Though these providers each independently often have electronic systems,

currently these systems are unable to communicate with each other.49

Our study has shown

that communication between settings is a fundamental element of RACF prescribing

processes. Electronic systems that work in isolation, or are designed for one setting only, can

aggravate risks such as information duplication. For health informatics researchers and

system designers, the challenge is to develop, implement and evaluate participatory design

methods that encompass involvement of all groups of users in the design of these systems.50-

53

Technology offers only a partial solution to the identified problems. Our findings emphasise

that technology-based interventions alone cannot address all system-related factors identified

in the study. The existing prescribing processes are driven by human resilience, where

participants compensate for missing, inaccurate and incomplete information through follow-up

with the team members concerned.54

A salient example of this included GPs ceasing a

medication prescribed for a resident while in hospital because the discharge summary had no

information about why the medication had been prescribed. However, we also identified team

and staff factors such as dispersion of responsibility, the short time availability of GPs and a

shortage of full-time RNs, which limit the capacity to exercise resilience. The consequence of

these system risk factors was prescribing errors, like missed medications that took up to 48

hours to be identified. To foster a safe prescribing environment it is vital to make the causes

of errors visible to those working in the system.53-55

Importantly, this should emphasise factors

contributing to errors and the establishment of a system to target these factors.55

Critically, in

our study sites, there was no formal process for error reporting or investigation.

We identified the distributed responsibility associated with the medication process to be a

significant problem. This problem was also reported in a 2009 UK study which explored the

prevalence and causes of medication errors in 55 care homes. That study identified an

absence of holistic responsibility for the safety of the medicines system as a major cause of

medication errors.15

A more recent study explored health providers’ views on barriers to

optimal antibiotic prescribing in Australian RACFs and found that distributed responsibility and

logistical issues such as limited availability of doctors hinder optimal antibiotic prescribing in

RACFs.56

One avenue is for GPs to participate in multidisciplinary initiatives like medication

advisory committee (MAC) meetings to convey the problems they face during prescribing.

However, time constraints and lack of incentives are the issues to be addressed to improve

GPs’ participation in these multidisciplinary initiatives. Improving the financial arrangements

for multidisciplinary initiatives and offering GPs the opportunity to engage in these meetings

remotely via teleconferencing (to address time constraints) may increase their participation.

The shortage of skilled nursing staff and inability to undertake regular medication audits at the

RACFs were safe prescribing risks identified. Enhancing the role of community pharmacists in

regular review and continuous monitoring of medications can facilitate the minimisation of risk

of prescribing errors. The Australian government funds pharmacists to provide collaborative

medication reviews with the GP for RACF residents, as well as Quality Use of Medicine

services to facilities.57

One medication review per resident is allowed per year, (excluding

where there is a change in the patient’s condition or medication), limiting their impact on

regular medication management issues faced by facilities. The Quality Use of Medicines

services provided by pharmacists to facilities include medication audits, education and

contributions to the MAC, and should assist in addressing some of the factors identified in this

study. Funding for these services only became available in the year of the study. Successful

implementation of these interventions on a large scale is dependent on teams which can work

collectively.58, 59

Simply mandating that interventions such as MAC meetings or collaborative

should be implemented, in the absence of any other strategies to ensure their adequate

implementation, is unlikely to be effective.

The staff management factors also highlight the need to introduce programs that develop

skills of RACF staff to proactively identify, assess and communicate issues which relate to

prescribing safety. Examples of these include developing skills on how to proactively seek

information across different settings (e.g. from hospitals, in the case of incomplete discharge

summaries) and how to perform active information review and handover (e.g. reviewing

charts immediately after prescribing, generating resident status reports prior to GP visits).

Formal quality improvement strategies that include development of communication tools and

training programs for RACFs staff are vital for individual skill development, organisational

learning and improving residents’ safety. The INTERACT II program in the USA is one such

example which provides a multitude of communication tools and strategies to enhance an

aged care facility’s ability to identify, evaluate and manage residents’ conditions before

residents require hospital transfer.60

Implementation of such programs encourages inclusion

of systems thinking approaches into training and practice of the care staff involved in

delivering care to residents.61

The factors identified in this study are based on observations and self-reports, which cannot

be regarded as definitive. One obvious limitation was the opportunistic choice of RACF sites.

The limited participation of GPs in the semi-structured interviews prevents conclusions

regarding their perceptions of prescribing issues. Nevertheless, we believe that the results

raise important issues requiring action, particularly given the scant research evidence about

medication safety in RACFs. Further empirical research to test the relationship between

different factors and types of prescribing errors in RACFs is warranted. While the study was

conducted within the under-researched context of residential aged care, the findings have

potential for application in collaborative health care settings. This research provides an

important basis from which to progress knowledge about system-related factors in

collaborative health care settings such as RACFs and to analyse their impact on aspects of

care delivery, medication management in this case, which are intrinsically linked to residents’

safety.

Conclusions

The study highlights several system-related factors which often act together to contribute to

the occurrence of prescribing errors, including antiquated and laborious methods for

exchanging information, dispersion of responsibility and shortage of skilled nursing staff at

RACFs. The study offers insights into the multi-factorial nature of causes underlying

prescribing errors in RACFs. To collectively address these issues, multifaceted interventions

comprising both technological and human elements are required. The complexity of

medication management in RACFs and associated system–related factors indicates a high

risk prescribing environment which has largely been unrecognised as such. Continuous

learning from system failures can minimise risk of prescribing errors occurring.

Competing Interest

The author(s) declare that they have no competing interests.

Acknowledgements

This study was funded by the NHMRC program grant ID No. 568612 which aimed to examine

patient safety across different health sectors in Australia. The program grant was

administered by Australian Institute of Health Innovation (AIHI). We thank RACF sites for their

participation and collaboration in this study.

Figure 1: A Resident's Medication Chart

Figure 2: Prescribing episode example 1- GP visits RACF on urgent request

Figure 3: Prescribing episode example 2- GP visits RACF to examine a resident discharged

from hospital

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