Managing and Administering Medication in Care Homes

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Managingandadministeringmedicationincarehomesforolderpeople

Contents

Page

Key

messages

1

1

Introduction

4

2 Theextentoftheproblem 1

3 Sourcesofmedicationadministrationerror 7

4

Monitoring

medication

11

5 Theuseoftechnologyandotheraids 11

6 Regulations,standards,guidanceandcodesofpractice 13

7

Making

a

difference

21

8 Concludingcomments 25

9 Referencesandfurtherreadings 27


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1

Key

messages

1.

Olderpeopleincarehomesareamongthemostvulnerablemembersofoursociety,relianton

carehomestaffformanyoftheireverydayneeds. Acombinationofcomplexmedicalconditions

mayleadtotheneedtotakemultiplemedicationswithcarehomeresidentstaking78

medicationson

average.

This

polypharmacy

in

turn

increases

the

risk

of

medication

error.

Medicationerrorsmayoccurasaresultofafailureinprescribing,dispensing,administeringor

monitoringmedication.

2.

Thisreportfocusesontheadministeringofmedicationincarehomes.Itlooksattheprevalence

oferror,commoncausesandhowthesecanbeaddressed,throughsimple,lowcostchangesin

practice,appropriatetrainingandmoresubstantivechangesincarehomesystems.

3. Respectfortheolderresidentandtheirdignityandrightsasanindividualshouldremainatthe

heartofthemedicationprocesswithmedicationbeingadministeredonbehalfoftheresident

ratherthan

to

the

resident.

4.

Theprincipleofthe5Rsofcorrectmedicationadministrationincarehomesremainssound,

rightresident,rightmedicationandrightdosebytherightrouteattherighttime.Inaddition,

thewelfare,rightsandvoiceoftheolderpersonreceivingmedicationhavetoremainatthe

heartoftheprocess.

5.

Thecarehomesuseofmedicines(CHUMS)studyobservedthaterrorsoccuron8.4%of

medicationadministrationevents.Thatwouldmeanthatacarehomeresidentbeing

administeredmedicationthreetimesadaywouldbe99.9%certaintoreceiveatleastone

medicationadministrationerroreverymonth.

6.

Themostcommontypesofmedicationadministrationerrorareincorrectcrushingof

medication,notsupervisingtheintakeofmedicationparticularlyforresidentswithdementia,

incorrecttiming,omissionsandwrongdose.

7. Errorsaremorecommoninthemorningthanlaterintheday.

8.

Thereisconflictingevidenceofwhethermedicationadministrationerrorsaremorelikelyin

residentialornursinghomecare,andthereisnoobviousrelationshipbetweenmedication

errorsandtypeofcarehomeownership,public,privateorvoluntary.

9.

Inhalersandliquidmedicationsaremuchmorelikelytogiverisetomedicationerrorsthan

tabletsbutitisunclearwhethermonitoreddosagesystems(MDS)areinherentlysafer.

Antibioticsmaybeparticularlypronetoerrorwithanumberofdosesbeingmissedoverthe

courseoftreatment.

10.Acommonlycitedcauseformedicationerrorsisinterruptionsduringthepreparationand

administrationofdrugs,withinterruptionstakinguparound11%ofmedicationadministration

time. Interruptionsareusuallybyothercarehomestaff.Anothercommonlycitedcauseisa

breakdownincommunicationaboutmedicationbetweenGP,hospital,pharmacyandcarehome


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2

duringaperiodoftransition,whentheresidentfirstentersacarehomeorreturnstothecare

homeafteraperiodinhospital.

11.

Residentsshouldbeinvolvedinthemedicationprocess.Amentallyalertresident,orfully

informedrelativeorfriendmaybethefinalcheckagainstmedicationerrorinthecarehome,but

manyresidents

are

passive

in

the

medication

process

saying

I

just

take

what

Im

given.

12.Theadministeringofmedicationsincarehomeiscurrently(October2011)coveredbyregulation

13oftheHealthandSocialcareAct2008(RegulatedActivities)Regulations2010and

complianceismonitoredbytheCareQualityCommission.

13.Standardsandguidanceonthehandlingandadministeringofmedicationincarehomesare

availablefromanumberofsources.TheRoyalPharmaceuticalSociety(ofGreatBritain)[2007]

andtheNursingandMidwiferyCouncil[2008]havepublishedstandardsandguidanceon

medicationincarehomes.TheRoyalPharmaceuticalSociety[2011]hasalsopublishedguidance

ongood

practice

when

patients/residents

transfer

between

care

providers.

Many

primary

care

trustshavepublishedguidanceandtemplatesofpoliciesandproceduresforcarehometo

adopt,someofwhicharelistedinthisreport,andtheSocialCareAssociation[2008]has

outlinedtwelveprinciplesofgoodpracticethatequallyapplytocarehomes.

14.Simple,lowcostoptionsthatmayreducethechanceofadministrationerror

Distributefreshwatertoallresidentsbeforethemedicationround

Avoidinterruptionsbythecareradministeringmedicationwearingabrightlycoloured

sleevelessjacketindicatingthatmedicationisbeingdispensedandrequestingtheyshould

notbe

disturbed

Withtheagreementoftheprescriber,administermedicationthatdoesnotneedtobe

administeredinthemorning,laterintheday

EnsurethatproceduresareinplacetorecordtheuseofPRN(asrequired)medicationonthe

medicationadministrationrecord(MAR)chartsothatstocklevelsaremaintained

Wherethisisnotalreadythecase,requestthatmedicine/medicationadministrationrecord

(MAR)chartsbesuppliedinaprintedformtoavoidincorrecttranscribinganddifficultto

readhandwriting

Requestthatthepharmacistsuppliesacopyof theoriginalmedicationinformationleaflet

(indications,contraindicationsandmethodofadministration)whenamedicationisfirst

suppliedtoanindividualresidentaspartofamonitoreddosagesystem

15.

Othersuggestedchanges.

Givingmedicationtothewrongresidentisrarebutseriouswhenitoccurs.Onestudyfound

that,overathreemonthperiod,overonehalfofresidentswereexposedtoanattemptto

givemedicationtothewrongresident. Attachingaphotographoftheresidenttothe


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medicationadministrationerroreveryweekandwouldbevirtuallycertain(99.9%chance)of

receivingatleastonemedicationadministrationerroreverymonth.

AUKevaluationofabarcodemedicationmanagementsysteminlongtermresidentialcare4,5

identified67medicationadministrationeventsperresidentperdaywitharound2errors

preventedby

the

system

per

resident

per

month.

The

most

common

error

was

giving

medication

at

thewrongtimealthough,overathreemonthperiodoveronehalfofresidents(52%)wereexposed

toanattempttogivemedicationtothewrongresident.

Notallmedicationerrorsoccurinthecarehome.Medicationerrorsmayoccuratthetimeof

prescribing,dispensingoradministeringthemedicationorthroughinadequatemonitoringofacare

homeresidentfollowingmedicationthatrequiresmonitoring. [Figure1] Whilecarehomestaffmay

onlyhavedirectresponsibilityforadministeringandmonitoringmedication,goodcommunication

betweencarehomestaffandtheprescribingGPorhospital,thedispensingpharmacistandother

healthcareprofessionalscanbejustasimportantinreducingthechanceoferrors.Thecarehome

useof

medicines

(CHUMS)

study3

found

that

one

half

(50%)

of

these

communication

errors

were

betweenthecarehomeandthepharmacy.

Figure1

Source:CHUMSstudy,2009

Therearesignsthatmedicationstandardsincarehomeshaveimprovedoverthepastdecadebut

thereisstillroomforfurtherimprovement.Underitspreviousregulatoryframework,theCare

4Szczepura,WildandNelson,2010


5


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StandardsAct2000,theCareQualityCommission(CQC)reportedthattheproportionofcarehomes

forolderpeoplereachingorexceedingthenationalminimumstandardonmedicationhadrisen

from45%in20023to70%in20089,anundoubtedimprovementbutleaving30%ofhomesstillnot

reachingthestandard.

Figure2

PercentageofcarehomesforolderpeoplemeetingNationalMinimumStandardsonmedication

Source:CareQualityCommission

Figure3

Morerecently,undertheHealthandSocialCareAct2008regulatoryframework,CQCfoundthat,

betweenOctober2010andJuly2011,theproportionofallcarehomesachievingfullcompliance

withOutcome9,onmanagementofmedicines,was61%forcarehomeswithnursingand72%for

carehomeswithoutnursing[Figure3],leavingroughly30% 40%ofhomesnotfullycompliant.

6


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Inasurveyofcarehomescarriedoutin2010/2011butnotpublisheduntil20126theCareQuality

Commissionreportedtheextenttowhichmedicationpolicieswereinplaceincarehomes.Most

homes(93%)alwaysrecordmedicineserrorsandhavearrangementsinplacetolearnfromthose

errorsbutwhile85%ofhomeshaveapolicyonhomely(overthecounter/nonprescription)

medicinesand84%keptananticoagulationrecordonly57%ofhomeshaveapolicycovering

decisionstoadministerPRN(asrequired)medication.Although39%ofhomesreportedthatgetting

medicationtoresidentsontimewassometimesoroftenaproblem,lessthanonehalfofhomes

(49%)recordtheactualtimeofadministrationofmedicines.

3.

THE

SOURCES

OF

MEDICATION

ADMINISTRATION

ERRORS

Commoncauses

AstudyofDutchcarehomes14

foundthemostcommoncausesofmedicationadministrationerror

wereincorrectcrushingofmedication,notsupervisingtheintakeofmedication,particularlyfor

residentswithdementia,andincorrecttimingmeasuredasmedicationbeingoveronehourearlyor

late.TheCHUMS7studyfoundthatnearlyonehalf(49.1%)ofadministrationerrorswereomissions

andmorethanonefifth(21.6%)werewrongdose.Theyidentifiedareasforpriorityattentionas

theMedicationAdministrationRecord(MAR)chartandinparticulardiscontinueddrugs,the

medicationroundandinparticularinterruptions,andcommunicationbetweenthepharmacyand

thecarehome.

Typeofcarehome

Thereis

conflicting

evidence

of

whether,

for

older

people,

residential

homes

or

care

homes

with

nursingperformbetterinthehandlingandadministrationofmedicines.CQCreportedthat,between

2002and2009,residentialhomesinitiallyperformedlesswellthannursinghomesinmeeting

nationalminimumstandardsbutimprovedsubstantiallyovertheperiodand,by2009,werevery

similarintheiroutcomes(Figure2).However,Inthedifferentlyformulated201011CQCmeasures,

nursinghomesoverallperformedlesswellthancarehomeswithoutnursing(Figure3).Thisisat

variancewiththeCHUMsstudy8 whichobservedthatolderpeopleinresidentialcare,received

twiceasmanymedicationadministrationerrors(MAE)asolderresidentsinnursingcareeven

thoughtheymadeupjust54%oftheresidentsstudied.Itishoweverinlinewitha2010studyofthe

effectivenessofpharmacymanagedbarcodemedicationmanagementsystems9whichfoundthat

theriskofapotentialmedicationadministrationerrorwas10%higherforresidentsinanursing

homethanforthoseinresidentialcare.

ArecentUSstudy10

foundthatalthoughtherenodirectassociationbetweenthetypeofownership

ofahome(public/voluntary/private)andthenumberofmedicationerrors,anotforprofithome

6CareQualityCommission,2012

7Barber,Alldred,Raynoretal,2009

8Alldred,Barber,Carpenteretal,2009


10Lane,

2010


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8

thatwaspartofachainhadonlyhalfthelevelofmedicationerrorscomparedwithaforprofithome

thatwasnotpartofachain.

Stafftrainingandqualifications

Commonsense

would

indicate

that

appropriate

staff

training

in

the

role,

effects

and

proper

administrationofmedication,forexampleinthecorrectuseofinhalers,wouldpromotebetter

understandingamongcarehomestaffandreducethechancesofmedicationerror. TheCareHomes

UseofMedicines(CHUMS)study8highlightedthisissuestatingthatstaffnumbers,skillsetsand

trainingmaybeimportantdeterminantsinmedicationadministrationerror. Trainingintheuseof

inhalersandtheimportanceofcorrecttimingofmedicationwereparticularlymentioned.

StudiesintheUSA11,12

havefoundconflictingevidenceaboutwhetherthelevelofqualificationof

carehomestaffhasanyinfluenceonmedicationerrors.AstudyinDutchcarehomes14

,however,

foundthatcarehomeworkerswithmoreexperiencemadefewererrorsandarecentstudyinthe

USA

13

found

that,

in

assisted

living,

workers

with

better

training

had

only

half

the

medication

administrationerrorrateofthosethatwerelesswelltrained.

Timeofday

Thereareindicationsthatmedicationadministeredinthefirsthalfoftheday(7amto2pm)istwice

aslikelytogiverisetoerrorsasmedicationadministeredintheevening14

.Thereasonsforthisare

unprovenbutmayrelatetothemorningbeingabusierpartofthecarehomeday.

Formulationanddeliveryprocess

Crushedmedication

is

nearly

eight

times

more

likely

than

tablets

to

give

rise

to

amedication

administrationerror14

. AfollowupanalysisoftheCHUMSstudydata15

foundthatinhalersand

liquidmedicineswereassociatedwithsignificantlyincreasedoddsofanadministrationerror.

Inhalersweretheworstsourceoferrorbeingover20timesmorelikelythanMDStabletstogiverise

toanerrorintheadministrationprocess.Topical(egeyedrops),transdermal(creams,ointments

etc)andinjectablemedicineswerearound14timesmorelikelytogiverisetoanerrorthanMDS

tabletsbut,becausethenumbersweresmall,theresultswerenotstatisticallysignificant.Common

faultswithliquidswereinaccuratemeasuringandnotshakingthebottle.

Antibiotics

Theadministeringofantibioticsincarehomesmaybeparticularlypronetoerror.AstudyinWales16

oftheadministrationofantibiotics(afixednumberofdosesadministeredatregularintervals)found

thatnearlyonefifth(18%)wereadministeredinappropriately,withanoverrunofmorethanone

11ScottCawiezelletal,2007

12Hughes,WrightandLapane,2006

13Zimmermanetal,2011

14VandenBemtetal,2009

15Alldredetal,2011

16Hinchliffe,

2010

referencing

Hussain

and

Walker,1999


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9

dayobserved,indicatingthatdoseshadbeenmissed.A2009studyinDutchnursinghomes17

found

thatantibioticswereovertentimesmorelikelytogenerateanadministrationerrorthanastandard

gastrointestinalmedication.

Interruptions

Whenaskedaboutbarrierstosafemedication,themostcommonbarriertothesafepreparationof

medicationscitedbynursesinBelgiancarehomeswasinterruptionswhilepreparingand

administeringmedication18

. Interruptionswerecitedasabarrierbyover40%ofnurses.ACanadian

timemotionstudyinalongtermcarefacility19

foundthatinterruptionsaccountedfor11.5%of

medicationadministrationtimewithatleastoneinterruptionin79%ofmedicationrounds. AUK

studyofhospitalmedicationrounds20

foundsimilarresultswithinterruptionstakingup11%ofthe

timeoneachmedicationround.TheUKCHUMSstudyofmedicationincarehomes21

,described

interruptionsasfrequentorconstant,particularlyduringthemorningdrugsround.Theiranalysis

oferrorreportsidentifiedinterruptionsasthemostsignificantcontributortoerroronthe

medicationround

with

an

interruption

occurring,

on

average,

every

15

minutes.

Over

60%

of

interruptionswerebyotherstaffwithover90%ofstaffinterruptionbeingaboutoperationalissues.

Fewerthan9%ofinterruptionswereverbalrequestsfromresidents.

Transitionsandcommunication

Itiswidelyacknowledgedthatresidentsmaybeparticularlyatriskofmedicationerrorduringa

periodoftransition,eitherwhentheresidentfirstentersacarehomeorwhenaresidentreturnsto

acarehomeafteraspellinhospital.Thismaybeasaresultofpoorcommunicationabout

medicationbetweentheresidentsownGPandthecarehome.Followingaperiodinhospital,

medicalnotes,

including

notes

of

any

change

in

medication,

may

be

sent

to

the

residents

GP

and

notnecessarilyimmediatelyfollowtheresidenttothecarehome.Overtwothirdsofthenursing

homesina2010USstudy22

reportedamedicationerrorduringthefirstsevendaysofaresidents

admission.TheCHUMSstudy23

intheUKfoundthat29%ofcommunicationrelatedmedication

errorswerebetweenthecarehomeandtheGPsurgeryalthoughthisrelatedtoallresidentsnotjust

neworreturningresidentsandwaslessthanthe50%ofcommunicationrelatedmedicationerrors

thatwerebetweenthecarehomeandthepharmacy.

AnAustralianstudy24

foundimprovedhealthoutcomesforresidentsforwhom,ontransferfrom

hospital,thecarehomewassentamedicationtransfersummaryandtherewasapharmacistled

medicationreview

within

10

14

days

of

admission

to

the

care

home.


18Dillesetal,2011

19Thomsonetal,2009

20Kreckleretal,2008


22Lane,2010


24Crotty

et

al,

2004

reviewed

in

LaMantia

et

al,

2010


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10

Theroleoftheresident

Residentsandtheirrelativesshouldbeencouragedtobeinvolvedandawareofthemedication

processwithselfmedicationbyresidentswheneverpossible. Amentallyalertresident,orrelatives

andfriendswhoknowtheresidentwell,canactasafinalcheckagainstmedicationerrors.National

policyemphasises

the

involvement

of

the

service

user.

National

Minimum

Standards,

following

the

CareStandardsAct2000andoperationaluntiltheimplementationoftheHealthandSocialCareAct

2008,statedServiceusers,whereappropriate,areresponsiblefortheirownmedication.The

replacementregulations,whilelessprescriptive,emphasisedtheinvolvementoftheresidentand

relativesandfriends.Peoplewhousetheservices,whereverpossible,willhaveinformationabout

themedicinebeingprescribedmadeavailabletothemorothersactingontheirbehalf.

TheWorkingtogethertodeveloppracticalsolutions:anintegratedapproachtomedicationincare

homesprojecthasdevelopedaResidentsChartertopromoteabetterunderstandingofhow

residentscanandshouldbeinvolvedintheadministrationoftheirmedication(seesection6.4).

A2009Dutchstudyofmedicationerrorsinnursinghomes25

foundDrugadministrationerrorsare

lesslikelytobeprevented,becausetheyoccurinthelaststageofthedrugdistributionprocess.This

isespeciallythecaseinnonalertpatients,aspatientsoftenformthefinalbarriertopreventionof

errors.

Althoughamentallyalertresidentshouldbethelastcheckagainstmedicationerrors,residents

oftenaccept,withoutquestion,thecontroloftheirmedicationbycarehomestaff.A2009studyof

residentsofnursinghomesinNorthernIreland26

reportedthatresidentsweregenerallyadherentto

medicationandhadlittleinvolvementineithertheprescribingoradministeringprocess.One

residentsaid

I

just

take

what

Iam

given.

Thelackofcommunicationandinformationsharingwithrelativesandcarers,aroundmedication,

wasoneofthemainissuesraisedasacauseofmedicationerrorsincarehomesina2011study27

of

theviewsofrelativesandcarers.Residents,relativesandcarers,ifmorefullyinvolvedandinformed,

cancontributebettertotheidentificationandeliminationofpotentialmedicationerrors.

PRN(prorenata whenorasrequired)medication

Becauseasrequiredmedicationisonlyreorderedwhenstocklevelsrequireit,itdoesnotformpart

oftheregulareverytimemedicationorderingadministeringreorderingcycleandcannotbepart

ofamonitored

dosage

system.

It

is

particularly

prone

to

lapses

in

keeping

adequate

supplies

of

the

medicationinreserveandisaparticularchallengeforrecordkeeping.

Prescribingmedicineasrequired,forexampleforlaxativesorsedativesisaneffectivewaytotreat

aresidentsufferingfromanacuteorirregularcondition.Thebenefitsofflexibilityarealsoopento

thedisbenefitsofmisuse.PRNmedicationshouldonlybeofferedwhenrequired,iewhen

symptomsareexhibited,andnotrestrictedtothenormalmedicationround.Aspecificplanfor


26HughesandGoldie,2009

27The

Health

Foundation,

2011


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11

ons32

.

administrationofthePRNmedicationmustberecordedandinformationaboutwhy,whenandhow

themedicationshouldbeadministered,togetherwithanyrestrictions(forexamplemax4dosesin

24hours),soughtfromtheprescriber,pharmacistorotherhealthcareprofessionalandrecordedon

theplanwhichshouldbekeptwiththeregularmedicineadministrationrecord(MAR)chart.28

PRN

medicationwillbeinitsoriginalpackagingandnotpartofamonitoreddosagesystem(MDS).A

recordofanyamountsadministeredwithdatesandtimesshouldberecordedontheMARchartand

theamountleftshouldberecordedoneachnewMARcharttoensurethemonitoringofstocklevels

andtimelyreordering.29

4.

MONITORING

MEDICATION

Manymedicinesmaybesafelyprescribedwithoutcarefulintensivefollowupmonitoringbutothers,

whereadverseunintendedsideeffectsarelikelyorthathaveahighriskoftoxicityorwheredosage

needstobeadjusted,maynecessitateregularandfrequentmonitoringofaresidentsprogress.The

CHUMS30

studyreportedthattheharmscoreformonitoringerrorswashigherthanforotherforms

oferror,whichreflectstheimportanceofmonitoringwhenitisrequired.Themostcommon

monitoringerrorsreportedintheCHUMSstudywerefordiuretics(55%)andACEinhibitors(16%).

While37%ofpreventabledrugrelatedmorbidityisassociatedwithalackofmonitoringof

drugs31

,withoverthreequartersinvolvingACEInhibitors,diureticsaccountfor16%ofmedicine

relatedhospitaladmissi

ArecentstudyinBelgiannursinghomes33

ofbarrierstosafemedicationmanagementfoundthat

nursesfeltthatbarrierstosafetyinmonitoringthesideeffectsofmedicationwerestrongerthan

barriersin

the

administration

of

the

medication.

Nurses

rated

highly,

as

barriers

to

safety

in

monitoring,theadverseeffectoflackofinformationfromthephysician,lackofcommunication

aboutsideeffects, lackofknowledgeaboutboththerapeuticeffectsandsideeffects,difficultyin

communicatingwiththephysicianandlackoftimetoperformthetaskwithcare.

5.

THE

USE

OF

TECHNOLOGY

AND

OTHER

AIDS

MonitoredDosageSystems(MDS)

MonitoredDosageSystems(MDS),inwhichthemedicationsforanindividualresidentataparticular

timeare

repackaged

by

the

pharmacist,

are

in

widespread

use

in

care

homes.

The

CHUMS

study

34

foundarangeofviewsaboutMDS.SomepharmacistsfeltthatMDSmadeiteasierforcarehome

stafftoadministermedicationsafelyandsystematicallywhileothersexpressedmorenegative

28CareQualityCommission,2008

29Gloucestershire CareServices,2010,http://www.glospct.nhs.uk/chst/chst_medicines.html


31Morrisetal,2004

32Howardetal,2007

33Dillesetal,2011



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12

opinionsincludingtheviewthatMDSwerenotsafeastabletscouldnotbeidentified.One

pharmacistnotedthatwhenatabletwasdroppedthestaffwouldnothaveareplacement.Another

saidthatMDSencouragedstaffnottolookatthelabel. AfollowupanalysisoftheCHUMSdata15

wasambivalentaboutwhetherMDSadministeredmedicationwassafer.Although,onthesurface,

errorrateswerebetterwithMDSadministeredmedication,themoreproblematicmedications,for

exampleliquidsandinhaleradministeredmedications,areoftennotpartoftheMDSsystemsso

comparisonwasnotoflikewithlike.Inadditionasrequired(PRN)medicationcannotbepartofthe

MDSsystem.ItisstillthereforeunclearwhetherornottraditionalMDSisinherentlysaferthan

originallypackagedmedication.ThereissomeevidencefromtheCHUMSstudy34

thatsingletablet

MDSblisterpacksmaybesaferthanMDScassettebasedsystemsandsomemorerecentMDSblister

systemscanalsoaccommodateliquids.

Pharmacymanagedbarcodemedicationmanagementsystems

Barcodebasedmedicationadministrationsystemshavethepotentialofreducingmedication

administrationerrors

in

care

homes

by

confirming

that

the

correct

medication

is

being

given

to

the

correctresidentattherighttime.AUKevaluationofonesuchsystem35

showeditseffectivenessin

avoidingalargenumberofcarehomemedicationadministrationerrorswhichwouldotherwisehave

occurred,butdidnotevaluatetheeaseofuseofthesystem.Hospitalbasedbarcodesystemslinked

toelectronicmedicationadministrationrecords(eMAR)havebeenshowntocompletelyeliminate

transcriptionerrors.36

Althoughtechnologybasedsolutionshavebeenshowntoreducemedicationadministrationerrors,

theywillonlybeembracedbycarehomestaffiftheyarereliable,easytouseanddonotadd

significantlytostaffworkloadforaparticulartask.Carehomestaffwillfindworkaroundsfor

workflowblockagesperceivedasunnecessary,eveniftheseareintentionalsafetychecksintroduced

bythesystem.37

Technologyisonlyacceptedwhenitworksproperlyandmakesaworkingtaskeasierormore

effective.A2008USstudyoftheuseofbarcodemedicationmanagementsystemsinhospitals

reportedthatnurseswereobservedtoworkaroundthesysteminanumberofwaysincluding

affixingpatientIDbarcodestothemedicationtrolley,andcarryingseveralpatientsprescanned

medicationsonthetrolley. Theneedforaworkaroundwascausedbyanumberofproblems

includingunreadablebarcodes,malfunctioningscanners,wornbatteries,poorwirelessconnection,

missingpatientwristbandsandnonbarcodedmedication.HospitalnursesoverrodeBCMAalerts

for4%ofpatientsand10%ofmedicines38

.


36Poonetal,2010

37Vogelsmeier,HalbeslebenandScottCawiezell,2008

38Koppel,

Wetterneck,

Telles

and

Karsh,

2008


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13

6.

REGULATIONS,

STANDARDS,

GUIDANCE

AND

CODES

OF

PRACTICE

Themanagementandadministrationofmedicinesincarehomesiscurrently(October 2011)

coveredbyregulation13oftheHealthandSocialCareAct2008(RegulatedActivities)Regulations

201039,40.

Thisstatesthat

Theregisteredpersonmustprotectserviceusersagainsttherisksassociatedwiththeunsafeuse

andmanagementofmedicines,bymeansofthemakingofappropriatearrangementsforthe

obtaining,recording,handling,using,safekeeping,dispensing,safeadministrationanddisposalof

medicinesusedforthepurposesoftheregulatedactivity.

Inmakingthearrangementsabovetheregisteredpersonmusthaveregardtoanyguidanceissued

bytheSecretaryofStateoranappropriateexpertbodyinrelationtothesafehandlinganduseof

medicines

Thespecifiedoutcomeoftheregulationisthatpeoplewhousetheservices:

Willhavetheirmedicinesatthetimestheyneedthemandinasafeway

Whereverpossiblewillhaveinformationaboutthemedicinebeingprescribedmade

availabletothemorothersactingontheirbehalf

Thisisbecauseproviderswhocomplywiththeregulationswill:

Handlemedicinessafely,securelyandappropriately

Ensurethatmedicinesareprescribedandgivenbypeoplesafely

Followpublishedguidanceabouthowtousemedicinessafely.

CompliancewiththeregulationsismonitoredbytheCareQualityCommission.Dependingonthe

circumstances,thehandlingofcontrolleddrugsmaybefurtherregulatedbytheMisuseofDrugsAct

Regulations2001.

AnumberoforganisationsincludingtheRoyalPharmaceuticalSocietyofGreatBritainandthe

NursingandMidwiferyCouncilhaveproducedstandardsandguidancefortheuseofmedicines.

Manypointsaredirectlyrelevanttocarehomes,althoughtheterminologyofpatientratherthan

residentandthenamedstaffinvolvedmaysometimesdiffer.Themainpointsaresummarisedbelow

forconvenience.

The2011

project

Working

together

to

develop

practical

solutions:

an

integrated

approach

to

medicationincarehomeshasalsodevelopedaframeworkguide:Makingthebestuseofmedicines

acrossallcaresettingswhichhighlightsexamplesofgoodpracticeformanagers,healthstaffand

residents.(Seesection6.4)

39CareQualityCommission,2010a

40Care

Quality

Commission,

2010b


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14

6.1.

RoyalPharmaceuticalSocietyofGreatBritainGuidance

TheRoyalPharmaceuticalSocietyofGreatBritainhaspublishedguidance,Thehandlingofmedicines

insocialcare.41

Theguidanceoutlineseightprinciplesrelatingtothesafeandappropriatehandling

ofmedicineswhichapplytoeverysocialcaresetting:

a)

Peoplehavefreedomofchoiceinrelationtotheirproviderofpharmaceuticalcareand

services,includingdispensedmedicines

b) Carestaffknowwhichmedicineseachpersonhas,andthecareservicekeepsacomplete

accountofmedicines

c) Carestaffwhohelppeoplewiththeirmedicinesarecompetent

d) Medicinesaregivensafelyandcorrectly,andcarestaffpreservethedignityandprivacy

oftheindividualwhentheygivemedicinestothem

e)

Medicinesareavailablewhentheindividualneedsthemandthecareprovidermakes

surethatunwantedmedicinesaredisposedofsafely

f) Medicinesarestoredsafely

g)

Thesocialcareservicehasaccesstoadvicefromapharmacist

h)

Medicinesareusedtocureorpreventdisease,ortorelievesymptomsandnottopunish

orcontrolbehaviour.

If

these

principles

are

to

be

achieved

there

needs

to

be

robust

arrangements

for

good

practice

and

communicationforallthoseinvolvedincludingGPs,hospitals,andcommunitypharmacistsaswellas

carestaff.

TheRPSGBguidelinesalsoindicatethatitisessentialthatcareworkerinresidentialcareforolder

peoplehaveawrittenpolicydocumentthatsetsout:

a) Howmedicinesareobtainedforresidents

b)

Procedurestoassessselfadministration

c)

Obtaining

residents

consent

if

care

workers

give

medicines

d)

Howmedicinesarestored,centrallyandforselfadministration

e) Proceduresforadministration

f) Procedurestoassesscompetencetoadministermedicinessafely

g)

Proceduresforcontrolleddrugs

h)

Proceduresforprovidingmedicineswhenresidentstakeleave

41Royal

Pharmaceutical

Society

of

Great

Britain,

2007


19/38

15

i)

Whatrecordsareheld

j)

Howtodealwithdrugerrorsandincidents

k)

Howtodisposeofmedicines

l)

Treatmentofminorailments

Theguidelinespointoutthatanalternativewaytostoremedicationisinindividuallockedmedicine

cupboardsordrawersinresidentsownrooms.Thiswouldbeessentialforselfmedicatingresidents

butcanalsobeusedinsystemswherecareworkersgivemedication.

6.2.

NursingandMidwiferyCouncilStandards

TheNursingandMidwiferyCouncilStandardsformedicinesmanagement42

,fornursesand

midwives,emphasisethefactthattheadministrationofmedicinesisnotjustamechanistictaskto

beperformedinstrictcompliancewiththewrittenprescriptionofamedicalpractitionerbutone

thatrequiresthoughtandtheexerciseofprofessionaljudgement.

Whenadministeringmedicationregisterednursesmust

becertainoftheidentityofthepatienttowhomthemedicineistobeadministered

checkthatthepatientisnotallergictothemedicinebeforeadministeringit

knowthetherapeuticusesofthemedicinetobeadministered,itsnormaldosage,side

effects,precautionsandcontraindications

beawareofthepatientsplanofcare(careplan/pathway)

checkthattheprescriptionorthelabelonmedicinedispensedisclearlywrittenand

unambiguous

checktheexpirydate(whereitexists)ofthemedicinetobeadministered

haveconsideredthedosage,weightwhereappropriate,methodofadministration,route

andtiming

administerorwithholdinthecontextofthepatientscondition(e.g.digoxinnotusuallyto

begivenifpulsebelow60)andcoexistingtherapiese.g.physiotherapy

contacttheprescriberoranotherauthorisedprescriberwithoutdelaywherecontra

indicationstotheprescribedmedicinearediscovered,wherethepatientdevelopsareaction

tothemedicine,orwhereassessmentofthepatientindicatesthatthemedicineisnolonger

suitable

42NursingandMidwiferyCouncil,2008


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16

makeaclear,accurateandimmediaterecordofallmedicineadministered,intentionally

withheldorrefusedbythepatient,ensuringthesignatureisclearandlegible;itisalsothe

responsibilityofthenursetoensurethatarecordismadewhendelegatingthetaskof

administeringmedicine.

Inaddition:

Wheremedicationisnotgiventhereasonfornotdoingsomustberecorded

AregisterednursemayadministerwithasinglesignatureanyPrescriptionOnlyMedicine

(POM),GeneralSalesList(GSL)orPharmacy(P)medication

InrespectofControlledDrugs:

Theseshouldbeadministeredinlinewithrelevantlegislationandlocalstandardoperating

procedures

ItisrecommendedthatfortheadministrationofControlledDrugsasecondarysignatoryis

requiredwithinsecondarycareandsimilarhealthcaresettings

Inapatientshome,wherearegistrantisadministeringaControlledDrugthathasalready

beenprescribedanddispensedtothatpatient,obtainingasecondarysignatoryshouldbe

basedonlocalriskassessment

Althoughnormallythesecondsignatoryshouldbeanotherregisteredhealthcare

professional(forexampledoctor,pharmacist,dentist)orstudentnurseormidwife,inthe

interest

of

patient

care,

where

this

is

not

possible

a

second

suitable

person

who

has

been

assessedascompetentmaysign.Itisgoodpracticethatthesecondsignatorywitnessesthe

wholeadministrationprocess.ForGuidance,goto:www.dh.gov.ukandsearchforSafer

ManagementofControlledDrugs:GuidanceonStandardOperatingProcedures

Incasesofdirectpatientadministrationoforalmedicationfromstockinasubstancemisuse

clinic,itmustbearegisterednursewhoadministers,signedbyasecondsignatory(assessed

ascompetent),whoisthensupervisedbytheregistrantasthepatientreceivesand

consumesthemedication

Aregisterednursemustclearlycountersignthesignatureofthestudentwhensupervisinga

studentintheadministrationofmedicines.

Selfadministration

Theregisterednurseisresponsiblefortheinitialandcontinuedassessmentofpatientswhoareself

administeringandhascontinuingresponsibilityforrecognisingandactinguponchangesina

patientsconditionwithregardstosafetyofthepatientandothers.


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17

6.3.

RoyalPharmaceuticalSocietygoodpracticeguidancefortransferbetweencareproviders

Oneofthetimesofgreatestriskofmedicationerrorforolderpeopleisatthepointsoftransition

betweenGPbasedhomecare,carehomecareandhospitalcare.

InJuly

2011,

the

Royal

Pharmaceutical

Society

published

Keeping

patients

safe

when

they

transfer

betweencareprovidersgettingthemedicinesright43

,atwopartgoodpracticeguideforhealthcare

professionals,providersandcommissioners.Althoughfocussingonhealthcareprofessionals,the

principlesofsoundinformationtransferareequallyapplicabletocarehomestaff.

Thisgoodpracticeguideoutlinedfourcoreprinciplesforhealthcareprofessionalsandthreekey

responsibilitiesfororganisationsprovidingcare,tominimisethechanceofmedicationerrorsarising

fromthetransferofresidents/patientsbetweencareproviders.

Fourcoreprinciplesforhealthprofessionals

1.

Healthcare

professionals

transferring

apatient

should

ensure

that

all

necessary

information

aboutthepatientsmedicinesisaccuratelyrecordedandtransferredwiththepatient,and

thatresponsibilityforongoingprescribingisclear

2. Whentakingoverthecareofapatient,thehealthcareprofessionalresponsibleshouldcheck

thatinformationaboutthepatientsmedicineshasbeenaccuratelyreceived,recordedand

actedupon

3. Patients(ortheirparents,carersoradvocates)shouldbeencouragedtobeactivepartners

inmanagingtheirmedicineswhentheymove,andknowinplaintermswhy,whenandwhat

medicinestheyaretaking

4.

Informationaboutpatientsmedicinesshouldbecommunicatedinawaywhichistimely,

clear,unambiguousandlegible;ideallygeneratedand/ortransferredelectronically.

Threekeyresponsibilitiesfororganisationsprovidingcare

1.

Providerorganisationsmustensurethattheyhavesafesystemsthatdefinerolesand

responsibilitieswithintheorganisation,andensurethathealthcareprofessionalsare

supportedtotransferinformationaboutmedicinesaccurately

2.

Systemsshouldfocusonimprovingpatientsafetyandpatientoutcomes.Organisations

shouldconsistentlymonitorandaudithoweffectivelytheytransferinformationabout

medicines

3. Goodandpoorpracticeinthetransferofmedicinesshouldbesharedtoimprovesystems

andencourageasafetyculture.

TheRoyalPharmaceuticalSocietyrecommendationsforthecorecontentsofarecordtobeused

whenpatientstransferbetweencareprovidersareshowninTable1.

43RoyalPharmaceuticalSociety,2011


22/38


23/38


24/38


25/38

7.

MAKING

A

DIFFERENCE

7.1.

Gettingitright the5Rsor5Cs

21

Whenadministeringmedicationincarehomesitisoftensaidthatthere

arefive

things

that

need

to

be

right

(5

Rs)

or

correct

(5

Cs).

These

are

right

orcorrectresident,rightmedication,rightdose,rightroute,andright

time.44

Rightroutereferstothewayinwhichthemedicationentersthebody,for

examplebymouth.

Someimprovementsintheadministeringofmedicationincarehomesare

veryeasytoachieve,otherrequirealittlemoreeffortandsomerequireevaluationandchangeof

thesystemsemployedinthecarehome.

7.2. Easytoachieveimprovements

Makesureallresidentshavewater

Residentsusuallyneedwatertotaketheirmedicationandtransportingwateronamedication

trolleyismessy,inconvenientandcanresultinspillage.46

Itisgoodpracticetoensurethatresidents

areregularlysuppliedwithfreshwatersoasimple,nocostimprovementwouldbetoensurethata

freshwaterroundimmediatelyprecedeseachmedicationround.

AvoidinterruptionsDonotdisturb.

Oneofthecausesofmedicationadministrationerrorsmostcommonlyraisedbystaffandidentified

inanumberofresearchreports46,47,48,49

isinterruptionofstaffwhiletheyarepreparingand

administeringmedication.Measurestoavoidinterruptionsareeasytoachieveatlittlecost.

Itis,however,importanttomaintaintheatmosphereofapproachabilityofcarehomestaffanda

simpleDoNotDisturbmessagemightgivethewrongimpressiontoresidentsandrelatives.A

brightlycolouredtabardwithsomethinglikePleasedonotdisturbwhileadministeringmedication

mightprovideawordofexplanationforrelativesandresidentswhilewarningotherstaffwho

providethevastmajorityofinterruptions.

Identificationofresidents

Carehomestaffusuallyknowtheirresidentsverywellbutnewandagencystaffmaybeunfamiliar

withresidents.Evenregularstaffmaymisidentifyresidentsfromtimetotime,particularlyones

withsimilarnames.Manymedicationadministrationrecord(MAR)chartsallowthepossibilityof

attachingaphotographoftheresidenttothecharttoaididentificationandthisprocedureshould

beadoptedwheneverpossible.


47Dillesetal,2011

48Thomsonetal,2009

49Kreckleretal,2008


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22

Maintainstocklevelsofasrequiredmedicines

PRN(asrequired)medicationdoesnotformpartoftheregularorderadministerreordercycleand

cannotbepartofamonitoreddosagesystem.ThatmeansthatstocklevelsofPRNmedicationhave

tobewatchedparticularlycarefully.PRNusageandtheamountremainingshouldberecorded on

theresidents

MAR

chart

and

care

taken

that

all

relevant

information

is

transferred

to

the

next

MAR

chartsothattheamountleft,recentdosageandanyrestrictionsonuse(egmaximumdoseina

giventimeperiod)areknown.AnadequateamountofPRNmedicationshouldbereorderedingood

time.

Correcttimingofmedication

Asrequiredmedicationshouldbeadministeredasrequired,whichmaynotbeatthetimeofthe

regularmedicationround. Timingofcertainregularmedicationsisalsoimportant,forexamplein

thetreatmentorParkinsonsdisease.Staffshouldbemadeawareoftheimportanceofgiving

medicinesat

the

correct

time,

even

when

this

does

not

match

the

time

of

the

regular

medication

round.

PrintedMARcharts

RoyalPharmaceuticalSocietyguidelines50

indicatethatmedicineadministrationcharts(MARcharts)

shouldbeclear,indelibleandpermanent. Asanaidtolegibility,carehomeshouldnowexpect

printedMARchartsfromtheircommunitypharmacist. PrintedMARchartsavoidadministration

errorsduetoclericalerror incorrectlytranscribingthedetailsfromanotherdocumentand

handwritingthatisdifficulttoreadandcanbemisunderstood.PrintedMARchartsshouldbe

reissuedifthereisasignificantchange,forexampleanewprescriptionforanacutemedication

duringthe

monthly

cycle.

Themorningmedicationround

Morningisthebusiestpartofthecarehomedayandmedicationadministrationerrorsaremore

prevalentinthemorning.Itthereforemakessensethat,withtheagreementoftheprescriber,

medicationsthatdonotneedtobeadministeredinthemorningareadministeredlaterintheday.

Improvingawareness

Trainingsessionstoimprovestaffawarenessofhowtoproperlyhandleandadministermedication

areoften

offered

to

care

homes

by

community

pharmacists.

Training

sessions

can

help

counteract

someverybasicerrorsthathavebeenobserved51

suchas:

a.

Dispersiblemedicationsmustbeadministeredinwater,notwhole

b.

Controlledreleasemedicationshouldbeadministeredwholeandnotsplitor

crushed

c. Incorrectuseofinhalers

d. Theimportantofstrictobservanceoftimingforcertainmedications

50RoyalPharmaceuticalSocietyofGreatBritain,2009



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23

7.3. Furtherimprovements

Storingmedicationsecurelyintheresidentsownroom

OneofthemedicationadministrationissueshighlightedbytheCHUMS52 studywasproblems

associatedwiththemedicationtrolleyandthemedicationround.Medicationtrolleysmaybe

difficulttomanoeuvreandiftheycannotbebroughtintocloseproximitytotheresidenthavetobe

madesecurewhilethemedicationisadministered.Itisarguedthatamedicationtrolleyismore

appropriatetoahospitalthanacarehomeenvironment.Theadvantagesofstoringmedicationina

smalllockablecabinetintheresidentsownroom arethatalltheresidentsmedications,including

PRN(asrequired)medication,arekepttogetheranddonothavetobetransportedaroundthecare

home.Medicationcanbetakeninprivacy,themedicationroundmaytakelesstimeandthereis

evidencethatmedicationadministrationerrorsarereduced53

.Issuestobeaddressedarethat

residentshave

to

be

in

their

own

rooms

at

the

time

of

medication

or

the

medication

brought

to

them,arrangementsstillhavetobemadeforrefrigeratedmedicationandtherehastobean

investmentintimecarefullydistributingmedicationatthetimeitarrivesfromthepharmacist.

MonitoredDosageSystems

MonitoredDosageSystems(MDS)havetheadvantageofsimplifyingthemedicationadministration

processbutthedisadvantageofseparatingmedicationfromitsoriginalpackaging.Althoughnotes

abouttheuseofindividualmedicationsshouldappearontheMARchart,andthemedicationshould

befullyidentifiedontheMDSpacks,itmightbebeneficialtoresidentsandcarehomestaff,inthe

caseof

MDS

medication,

to

request

from

the

pharmacist

acopy

of

the

original

medication

informationleaflet(indications,contraindicationsandmethodofadministration)whena

medicationisfirstsuppliedforanindividualresident.

CommunicationwiththeGPpractice

CarehomeresidentsarecommonlyunabletovisittheirGPandrequiretheGPtovisitthecare

home.GPs,ontheotherhand,makeveryfewhomevisitsandaregeareduptoreceivepatientsat

thesurgery,consultingpatientnotesonthesurgeryITsystem.Whereacarehomehasasmall

numberofpreferredGPsitwouldbepossibletoestablishasecureITlinkfromthecarehometo

thesurgeryITsystemsothattheGPcanconsultpatientnotesandupdatethemwhenvisitingthe

carehome.TheITlinkalsomeansthatcomputerbasedprescriptionsmaybegeneratedinthehome

andsignedbytheGPduringavisit.SuchalinkislikelytobringaboutareductioninGPprescribing

andmonitoringerrorsratherthancarehomemedicationadministrationerrors.


53Pharmaceutical Journal,2002


28/38

7.4.

Improvingthesystem

Leaderwithkeyresponsibility

Thereshould

be

an

appointed

person

within

the

care

home

who

has

overall

responsibility

for

medicationadministrationprocessesandwhocanprovideleadershipandguidancetoothercare

homestaff.Inasmallcarehomethismaybetheregisteredmanageroranassistantbutinalarger

home,whiletheregisteredmanagerretainsoverallresponsibility,thisrolemaybedelegatedtoa

suitablyqualified,responsibleperson.

Reviewbyapharmacist

TheCHUMSstudy54

recommendedthatcarehomesshouldcommissionanindependentreviewof

theirmedicationprocessesbyanoutsideperson,possiblyapharmacist,whocouldprovidean

overviewoftheeffectiverunningofthewholemedicinessysteminthehome,andoflinkswiththe

associatedGPs,supplyingpharmacistsandthePCT.

Trainingofcarehomestaff

Improvementsinmedicationadministrationsafetythatfollowfromappropriatestafftrainingare

commonsenseandwellproven.55,56

Apolicyonmedicationtrainingfornewstaffandrefresher

sessionsforexistingstaffneedstobeestablishedinthecarehome.Communitypharmacistswill

oftenprovidetrainingsessionsandcertifiedmedicationtrainingmaybeavailablethroughthelocal

authorityorPCT.

Table4

Relevantevidencebasedguidanceandalertsaboutmedicines

managementandgoodpracticepublishedbyappropriateexpertand

professionalbodies,including:

NationalPatientSafetyAgency

NationalInstituteforHealthandClinicalExcellence

MedicinesandHealthcareproductsRegulatoryAgency

DepartmentofHealth

RoyalPharmaceuticalSocietyofGreatBritain(RPSGB)

SocialCareInstituteforExcellence

Medicalandotherclinicalroyalcolleges,facultiesand

professionalassociations

Thesafeandsecurehandlingofmedicines:ateamapproach(RPSGB,

2005)

Safermanagementofcontrolleddrugs:Guidanceonstrengthened

governancearrangements(DH,2007)

Safermanagementofcontrolleddrugs:Guidanceonstandard

operatingproceduresforcontrolleddrugs(DH,2007)

Thehandlingofmedicinesinsocialcare(RPSGB,2007)

Researchgovernanceframeworkforhealthandsocialcare:Second

edition(DH,2005)

24


55Zimmermanetal,2011



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25

7.5.

Informationsourcesforcarehomemanagers

Aswellastheregulations,guides,standardsandcodesofpracticeonmedicationadministrationin

carehomesreferencedinthisdocument,theCareQualityCommission57

intheir2010guidance

recommendthesourcesshowninTable4tohelpachievecompliancewithOutcome9

Managementof

medicines.

8. CONCLUDINGCOMMENTS

TheCHUMSstudyandmanyotherresearchprojectshavehighlightedthecontinuingproblemofthe

highlevelofmedicationerrorsincarehomes.Notallerrorsareinthehandsofcarehomestaff.

TheremaybeprescribingerrorsattheGPsurgeryorhospitalanddispensingerrorsatthepharmacy.

Carehomemanagersandstaffcanhoweverdosomethingtoimprovetheadministrationand

monitoringofmedicationincarehomesaswellasmaintainingvigilanceforsuspectedprescribingor

dispensingerrorsthatcanbequeriedwiththesurgeryorpharmacy,particularlywhenresidentsfirst

arriveatthecarehomeorreturnfromhospital.

Thecarehomeresidentshouldbeseenasattheheartofthemedicationadministrationprocess,

perhapsasacustomerforwhomaserviceisbeingprovidedbutcertainlyasahumanbeingwhos

dignity,rightsandpreferencesareofparamountimportance.Aswithmanyotheraspectsofcare

homecare,theadministeringofmedicationshouldadoptaresidentcentredapproach.

Itistheresponsibilityofthecarehometoensurethatadequatesystemsformanaging,

administeringandmonitoringmedicationareinplaceandareviewofmedicationsystemsbyan

outsideprofessional,

for

example

apharmacist,

may

help

to

identify

any

deficiencies.

Medicationadministrationerrorsarenotintentionalandariseeitherfromasystemsfailureorfrom

alackofawarenessorstressandtirednessonthepartofstaff.Awarenesscanbeimprovedby

appropriatetraining,andstressandtirednesscanbereducedbyappropriatelevelsofstaffingand

organisationinthecarehome.Howeverevenwelltrained,wellrested,staffwilloccasionallymake

mistakes,andmistakeswithmedication,especiallywithfrailolderpeople,canbeparticularly

dangerous.

Theissuesraisedinthisreporthelptohighlightwaysinwhichsystemscanbestrengthenedtohelp

staffavoid

medication

administration

errors.

Some

ideas

such

as

making

sure

all

residents

have

waterbeforethemedicationround,avoidinginterruptionsandaskingforcopiesoforiginal

medicationinformationleafletsarerelativelyeasytoachieve.Others,suchasensuringMARcharts

areprintedandhavephotographsoftheresident,oraskingthatmedicationwhichdoesnothaveto

betakeninthemorningbeprescribedforlaterintheday,maytakealittlemoreefforttosetup.

Trainingtoimprovestaffawarenessisakeyfactortoimprovemedicationsafetyandstoring

medicationsecurelyintheresidentsownroomrecognisesthatthemedicationisthepropertyof

theresidentwhileatthesametimereducingtheriskoferror.

57CareQualityCommission,2010a


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26

Providingasecurecommunicationlinkfromthecarehometothepracticebasedcomputersystem

ofvisitingGPshasclearbenefitsfortheresident,GPandcarehomeandmaynotbeparticularly

difficulttoachieve.

Inthefuturetechnologymaylendahand,withbarcodebasedscanningsystemsalreadyinusein

somecare

homes

to

correctly

identify

the

resident,

medication,

dose

and

time.

Early

adopters

of

the

technologywillironoutanyinitialproblemsandeaseofuseandcostwillbethedeterminingfactors

foruptake.

Theprincipleofthe5Rs,rightresident,rightmedication,rightdose,rightrouteandrighttimehas

beenaroundforsometimeandissometimessupplementedbya6th

R,theresidentsrighttorefuse

medicationwhentheyhavementalcapacity.ThislastRisarecognitionthattheresidentisatthe

heartofthemedicationprocessandthatmedicationadministrationisonbehalfoftheresident.

Whatisstrikingisthattherehasbeenanawarenessofmedicationadministrationproblemsincare

homesfor

some

time

and

many

of

the

solutions

suggested

have

not

changed.

In

2004

the

National

CareStandardscommissionidentifiedexcellenttrainingonmedicationandtheuseofphotographs

tocorrectlyidentifyresidentsascharacteristicsofgoodperformanceincarehomes.58

Goodmonitoringandcommunicationbetweeneveryoneinvolvedingettingthecorrectprescribed

drugstothecarehomeresidentisessential.Technologybasedsolutionshavebeenshowntoreduce

medicationadministrationerrors,buttheywillonlybeembracedbycarehomestaffiftheyare

reliable,easytouseanddonotaddsignificantlytostaffworkloadforaparticulartask.

Whateversolutionsareadoptedtoreducemedicationadministrationerrorsincarehomes,the

residentandtheirdignity,rightsandneedsshouldremainparamountwithmedication

administrationbeingonbehalfoftheresidentratherthantotheresident.

58 Daviesetal2004


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27

9.

REFERENCES

AND

FURTHER

READINGS

AlldredDP,BarberN,BuckleP,CarpenterJ,DickinsonR,FranklinBD,GarfieldS,JessonB,LimR,

RaynorDK,SavageI,StandageC,WadsworthP,WoloshynowychMandZermanskyAG(2009)Care

homeuseofmedicinesstudy(CHUMS):Medicationerrorsinnursing&residentialcarehomes

prevalence,consequences,

causes

and

solutions,

London:

Report

to

the

Patient

Safety

Research

Portfolio,DepartmentofHealth

AlldredDP,StandageC,FletcherO,SavageI,CarpenterJ,BarberNandRaynorDK(2011)The

influenceofformulationandmedicinedeliverysystemonmedicationadministrationerrorsincare

homesforolderpeople,BMJQualityandSafety20(5):397401

AlldredDP,StandageC,ZermanskyAG,BarberND,RaynorDKandPettyDR(2010)Therecording

ofdrugsensitivitiesforolderpeoplelivingincarehomes,BritishJournalofClinicalPharmacology69

(5):553557

AlldredDandStandageC(2011)Medicationerrorsincarehomes,NursingTimes107(24):2127

AspinallS,SevickMA,DonohueJ,MaherRandHanlonJT(2007)Medicationerrorsinolderadults:

Areviewofrecentpublications,AmericanJournalofGeriatricPharmacotherapy5(1):7584

BanningM(2007)Medicationreviewfortheolderperson,ReviewsinClinicalGerontology17(1):

2532

BarberN

D,

Alldred

D

P,

Raynor

D

K,

Dickinson

R,

Garfield

S,

Jesson

B,

Lim

R,

Savage

I,Standage

C,

BuckleP,CarpenterJ,FranklinB,WoloshynowychMandZermanskyAG.(2009)Carehomes'useof

medicinesstudy:prevalence,causesandpotentialharmofmedicationerrorsincarehomesforolder

people,Quality&SafetyinHealthCare18(5):341346

BerryB(1994)Safetywithdignity,CareWeekly344:14

BissellP,BlenkinsoppA,ShortDandMasonL(2008)Patients'experiencesofacommunity

pharmacyledmedicinesmanagementservice,HealthandSocialCareintheCommunity16(4):363

369

BurnhamT(2012)Medicationproblemsofolderpeople:annotatedbibliographyofpublications,

NationalelectronicLibraryforMedicines,MedicinesManagementOverview

BurnsP,PerkinsDA,LarsenKandDalleyA(2007)Theintroductionofelectronicmedicationcharts

andprescribinginagedcarefacilities:Anevaluation,AustralasianJournalonAgeing26(3):131134

CareQualityCommission(2008)CQCPharmacytip:Medicationprescribedtobetakenwhenrequired

(27October2008),London:CareQualityCommission


32/38

28

CareQualityCommission(2010a)Guidanceaboutcompliance:Essentialstandardsforqualityand

safety,London:CareQualityCommission

CareQualityCommission(2010b)Guidanceaboutcompliance:Summaryofregulations,outcomes

andjudgementframework,London:CareQualityCommission

CareQualityCommission(2011)ThestateofhealthcareandadultsocialcareinEngland:An

overviewofkeythemesincarein2010/11:PresentedtoParliamentpursuanttosection83(4)(a)of

Part1oftheHealthandSocialCareAct2008.,London:TheStationeryOffice

CareQualityCommission(2012)Healthcareincarehomes:Aspecialreviewoftheprovisionof

healthcaretothoseincarehomes,London:CareQualityCommission

CarersUK(2009)Makingthemostofpharmaciesforcarers:Medicines,London:CarersUK

CentreforPolicyonAgeingforBupa(2011)Thechangingroleofcarehomes,(forthcoming)

ChanS(2008)Factorsassociatedwiththeuseofelectronicinformationsystemsfordrugdispensing

andmedicationadministrationrecordsinnursinghomes,JournaloftheAmericanMedicalDirectors

Association9(6):414421

ChhabraPT,RattingerGB,DutcherSK,HareME,ParsonsKLandZuckermanIH(2011)Medication

reconciliationduringthetransitiontoandfromlongtermcaresettings:Asystematicreview,

ResearchinSocialandAdministrativePharmacy(RSAP)April20.

CommissionforSocialCareInspection(2006)Handledwithcare?Managingmedicationforresidents

ofcarehomesandchildren'shomesAfollowupstudy(CSCIspecialstudyreport),

CommissionforSocialCareInspection(2008)ProfessionalAdvice:Medicineadministrationrecords

(MAR)incarehomesanddomiciliarycare,London:CSCI:Quality,PerformanceandMethods

Directorate

CrespinDJ,ModiAV,WeiD,WilliamsCE,GreeneSB,PiersonSandHansenRA(2010)Repeat

medicationerrorsinnursinghomes:Contributingfactorsandtheirassociationwithpatientharm,

AmericanJournalofGeriatricPharmacotherapy8(3):258270

CrottyM,RowettD,SpurlingL,GilesLCandPhillipsPA(2004)Doestheadditionofapharmacist

transitioncoordinatorimproveevidencebasedmedicationmanagementandhealthoutcomesin

olderadultsmovingfromthehospitaltoalongtermcarefacility?Resultsofarandomized,

controlledtrial,TheAmericanJournalofGeriatricPharmocotherapy2(4):257264

CrownJ(chairman)ReviewTeamforthePrescribing,SupplyandAdministrationofMedicines;

DepartmentofHealth(1999)Reviewofprescribing,supplyandadministrationofmedicines,London:

Departmentof

Health


33/38

29

DaviesT,DalleyG,UnsworthL,WallerMandDrysdaleC;NationalCareStandardsCommission

NCSC(2004)Themanagementofmedicationincareservices200203,London:TheStationeryOffice

DillesT,ElseviersMM,VanRompaeyB,VanBortelLMandSticheleRR(2011)Barriersfornursesto

safemedicationmanagementinnursinghomes,JournalofNursingScholarship43(2):171180

EdgarCandHarveyP(2010)CommonMedicationErrorsinLongTermCareSettingsIn:Medication

ManagementinOlderAdults:Aconciseguideforclinicians,NewYork:Springer:5367

FreerCandWarringtonH(1994)Straightfromthepack,ElderlyCare6(1):3031

FreyD(ed)(2005)Improvingmedicationmanagementinhomecare:Issuesandsolutions,Home

HealthCareServicesQuarterly24(1/2):1146

FurnissL(2002)Useofmedicinesinnursinghomesforolderpeople,AdvancesinPsychiatric

Treatment8:198204

FurnissL,LloydCraigSKandBurnsA(1998)Medicationuseinnursinghomesforelderlypeople,

InternationalJournalofGeriatricPsychiatry13(7):433439

GloucestershireCareServices(2010)Medicinesmanagementforcarehomes,

http://www.glospct.nhs.uk/chst/chst_medicines.html

GreeneSB,

Williams

CE,

Pierson

S,

Hansen

R

A

and

Carey

TS(2011)

Online

medication

error

graphic

reports:ApilotinNorthCarolinanursinghomes,Journalofpatientsafety7(2):9298

GriffithR(2003)Thelawandprescribingpractice[Part1],GeriatricMedicine33(7):1115

GriffithR(2003)Thelawandprescribingpractice[Part2],GeriatricMedicine33(8):1113

HansenRA,CornellPY,RyanPB,WilliamsCE,PiersonSandGreeneSB(2010)Patternsinnursing

homemedicationerrors:Disproportionalityanalysisasanovelmethodtoidentifyquality

improvementopportunities,Pharmacoepidemiology&DrugSafety19(10):10871094

TheHealthFoundation(2011)Makingcaresafer:Improvingmedicationsafetyforpeopleincare

homes:Thoughtsandexperiencesfromcarersandrelatives,London:TheHealthFoundation

HinchliffeA(2010)Medicationadministrationerrorsincarehomes,NHSWales,PublicHealthWales

HodgkinsonB,KochS,NayRandNicholsK(2006)Strategiestoreducemedicationerrorswith

referencetoolderadults,InternationalJournalofEvidenceBasedHealthcare4(1):241

HollandR,

Desborough

J,

Goodyer

L,

Hall

S,

Wright

D

and

Loke

YK(2007)

Does

pharmacist

led


34/38

30

medicationreviewhelptoreducehospitaladmissionsanddeathsinolderpeople?Asystematic

reviewandmetaanalysis,BritishJournalofClinical65(3):303316

HowardRL,AveryAJ,SlavenburgS,RoyalS,PipeG,LucassenPandPirmohamedM(2007)Which

drugscausepreventableadmissionstohospital?Asystematicreview,BritishJournalofClinical

Pharmacology63(2):136147

HughesCM(2008)Compliancewithmedicationinnursinghomesforolderpeople:Resident

enforcementorresidentempowerment?,Drugs&Aging25(6):445454

HughesCMandGoldieR(2009)"IjusttakewhatIamgiven":Adherenceandresidentinvolvement

indecisionmakingonmedicinesinnursinghomesforolderpeople:Aqualitativesurvey,Drugs&

Aging25(6):505517

HughesC,

Wright

R

and

Lapane

K(2006)

Use

of

medication

technicians

in

US

nursing

homes:

Part

of

theproblemorpartofthesolution?,JournaloftheAmericanMedicalDirectorsAssociation7(5):

294304

HussainMandWalkerR(1999)Providercompliancewithantibioticadministrationinnursinghomes

andresidentialhomes,PharmaceuticalJournal263(7063):R30R31

Jesson,B(2008)ReviewofMedicinesmanagementforresidentialandnursinghomes,International

Psychogeriatrics20(1):204205

KaasalainenS,

Agarwal

G,

Dolovich

L,

Papaioannou

A,

Brazil

Kand

Akhtar

Danesh

N

(2010)

Nurses'

perceptionsofandsatisfactionwiththemedicationadministrationsysteminlongtermcarehomes,

CanadianJournalofNursingResearch42(4):5879

KirkevoldOandEngedalK(2010)Whatisthematterwithcrushingpillsandopeningcapsules?,

InternationalJournalofNursingPractice16(1):8185

KoppelR,WetterneckT,TellesJLandKarshBT(2008)Workaroundstobarcodemedication

administrationsystems:Theiroccurrences,causes,andthreatstopatientsafety,Journalofthe

AmericanMedicalInformaticsAssociation15:408423

KrecklerS,CatchpoleK,BottomleyM,HandaAandMcCullochP(2008)Interruptionsduringdrug

rounds:Anobservationalstudy,BritishJournalofNursing17(21):13261330

LaMantiaMA,ScheunemannLP,VieraAJ,BusbyWhiteheadJandHansonLC(2010)Interventions

toimprovetransitionalcarebetweennursinghomesandhospitals:Asystematicreview,Journalof

theAmericanGeriatricsSociety58(4):777782

LaneSJ(2010)Theassociationofstructuralandprocessfactorswithmedicationerrorsforresidents

enteringanursing

home,

PsycINFO

Dissertation

Abstracts

International:

Section

B:

The

Sciences

and


35/38

31

Engineering71(1B)

LilleyR,LambdenPandGilliesA(2007)Medicinesmanagementforresidentialandnursinghomes:A

toolkitforbestpracticeandaccreditedlearning,Abingdon,Oxon:RadcliffePublishing

LimLM,ChiuLH,DohrmannJandTanKL(2010)Registerednurses'medicationmanagementofthe

elderlyinagedcarefacilities,InternationalNursingReview57(1):98106

LoganathanM,SinghS,FranklinBD,BottleAandMajeedA(2011)Interventionstooptimise

prescribingincarehomes:Systematicreview,AgeandAgeing40(2):150162

MaidmentI,HawC,StubbsJ,FoxC,KatonaCandFranklinBD(2008)Medicationerrorsinolder

peoplewithmentalhealthproblems:Areview,InternationalJournalofGeriatricPsychiatry23(6):

564573

MariniSDandHasmanA(2009)ImpactofBCMAonmedicationerrorsandpatientsafety:a

summary,StudiesinHealthTechnologyandInformatics146:439444

MilliganFJ,KrentzAJandSinclairAJ(2011)Diabetesmedicationpatientsafetyincidentreportsto

theNationalReportingandLearningService:thecarehomesetting,DiabeticMedicine28(12):

15371540

MittyEandFloresS(2007)Assistedlivingnursingpractice:medicationmanagement:Part2

supervisionandmonitoringofmedicationadministrationbyunlicensedassistivepersonnel,Geriatric

Nursing28

(3)

:153

160

MorrisCJ,RodgersS,HammersleyVS,AveryAJandCantrillJA(2004)Indicatorsforpreventable

drugrelatedmorbidity:Applicationsinprimarycare,QualityandSafetyinHealthCare13:181185

NationalPharmaceuticalAssociation(1998)Medicationmanagement:Everybody'sproblem:

Strategiestomeettheneedsofvulnerablepeople,StAlbans:NationalPharmaceuticalAssociation

NishtalaPS,HilmerSN,McLachlanAJ,HannanPJandChenTF(2009)Impactofresidential

medicationmanagementreviewsondrugburdenindexinagedcarehomes:Aretrospective

analysis,Drugs&Aging26(8):677686

NixonP(1996)Hominginondrugrounds,NursingTimes92(16):5960

Nursing&MidwiferyCouncil(2008)Standardsformedicinesmanagement,London:NMC

OuslanderJG,OsterweilDandMorleyJ(1997)Medicalcareinthenursinghome,NewYork:

McGrawHill

ParsonsC,

Johnston

S,

Mathie

E,

Baron

N,

Machen

I,Amador

Sarah

and

Goodman

C

(2012)


36/38

32

Potentiallyinappropriateprescribinginolderpeoplewithdementiaincarehomes:Aretrospective

analysis,doi:10.2165/1159856000000000000000Drugs&Aging29(2):143155

ParsonsC,LapaneK,KerseNandHughesC.(2011)Prescribingforolderpeopleinnursinghomes:A

reviewofthekeyissues,InternationalJournalofOlderPeopleNursing6(1):4554

PepperG.AandTowsleyGL(2007)Medicationerrorsinnursinghomes:Incidenceandreduction

strategies,JournalofPharmaceuticalFinanceEconomicsandPolicy16(1):559

PharmaceuticalJournal(2002)Givingmedicinesfrompatientlockersreduceserrors,Pharmaceutical

Journal268(7187):274279

PiersonS,HansenR,GreeneS,WilliamsC,AkersR,JonssonMandCareyT(2007)Preventing

medicationerrorsinlongtermcare:Resultsandevaluationofalargescalewebbasederror

reportingsystem,

Quality

&

Safety

in

Health

Care

16

(4)

:297

302

PoonEG,KeohaneCA,YoonCS,DitmoreM,BaneA,LevtzionKorachO,MonizT,RothschildJM,

KachaliaAB,HayesJ,ChurchillWW,LipsitzS,WhittemoreAD,BatesDWandGandhiTK(2010)

Effectofbarcodetechnologyonthesafetyofmedicationadministration,NewEnglandJournalof

Medicine362:16981707

RandolphPKandScottCawiezellJ(2010)Developingastatewidemedicationtechnicianpilot

programinnursinghomes,JournalofGerontologicalNursing36(9):3644

RobertsM

S,

King

M,

Stokes

JA,

Teresa

A.

Lynne

TA,

Bonner

CJ,

Mccarthy

S,

Wilson

A,

Glasziou

P

andPughWJ(1998)Medicationprescribingandadministrationinnursinghomes,AgeandAgeing

27(3):385392

RoyalPharmaceuticalSociety(2011a)Keepingpatientssafewhentheytransferbetweencare

providers gettingthemedicinesright.Part1 Goodpracticeguidanceforhealthprofessional,

London:RoyalPharmaceuticalSociety

RoyalPharmaceuticalSociety(2011b)Keepingpatientssafewhentheytransferbetweencare

providers gettingthemedicinesright.Part2AguideforprovidersandcommissionersofNHS

service,London:RoyalPharmaceuticalSociety

RoyalPharmaceuticalSocietyofGreatBritain(1994)Theadministrationandcontrolofmedicinesin

residentialandchildren'shomes,London:RoyalPharmaceuticalSocietyofGreatBritain

RoyalPharmaceuticalSocietyofGreatBritain(2007)Thehandlingofmedicinesinsocialcare,

London:RoyalPharmaceuticalSocietyofGreatBritain

RoyalPharmaceuticalSocietyofGreatBritain(2009)Principlesofsafeandappropriateproductionof

medicineadministration

charts,

London:

RPSGB


37/38

33

RutterTandBarnettN(2007)Amilestoneinselfmanagement:[principlestouseformanagement

ofmedicines],HealthServiceJournal117(6064):2829

ScottCawiezellJ,MadsenRW,PepperGA,VogelsmeierA,PetroskiGandZellmerD(2009)

Medicationsafetyteams'guidedimplementationofelectronicmedicationadministrationrecordsin

fivenursinghomes,JointCommissionJournalonQuality&PatientSafety35(1):2935

ScottCawiezellJ,PepperGA,MadsenRW,PetroskiG,VogelsmeierAandZellmerD(2007)Nursing

homeerrorandlevelofstaffcredentials,ClinicalNursingResearch16(1):7278

SmithJ(ChiefPharmaceuticalOfficer DepartmentofHealth)(2004)BuildingasaferNHSfor

patients:Improvingmedicationsafety,London:DepartmentofHealth

SocialCare

Association

(2008)

Medication

administration

in

social

care,

London:

SCA

SommervilleH(2008)Professionaladvice:Thesafemanagementofcontrolleddrugsincarehomes,

London:CommissionforSocialCareInspection

SzczepuraA,WildDandNelsonS(2010)Preventingmedicationadministrationerrorsusing

pharmacymanagedbarcodemedicationmanagementsystemsinlongtermresidentialcare,

WarwickResearchArchivePortalhttp://wrap.warwick.ac.uk/3226/

SzczepuraA,WildDandNelsonS(2011)Medicationadministrationerrorsforolderpeopleinlong

termresidential

care,

http://www.biomedcentral.com/1471

2318/11/82

BMC

Geriatrics

11

(82)

ThomsonMS,GruneirA,LeeM,BarilJ,FieldTS,GurwitzJHandRochonPA(2009)Nursingtime

devotedtomedicationadministrationinlongtermcare:Clinical,safety,andresourceimplications,

JournaloftheAmericanGeriatricsSociety57:266272

VandenBemtPM,IdzingaJC,RobertzH,KormelinkDGandPelsN(2009)Medication

administrationerrorsinnursinghomesusinganautomatedmedicationdispensingsystem,Journal

oftheAmericanMedicalInformaticsAssociation16(4):486492

VandenBemtPMLA,RobertzR,deJongAL,vanRoonENandLeufkensHGM(2007)Drug

administrationerrorsinaninstitutionforindividualswithintellectualdisability:Anobservational

study,JournalofIntellectualDisabilityResearch51(7):528536

VerrueCL,MehuysE,SomersA,VanMaeleG,RemonJPandPetrovicM(2010)Medication

administrationinnursinghomes:Pharmacists'contributiontoerrorprevention,Journalofthe

AmericanMedicalDirectorsAssociation11(4):275283

VerrueC,PetrovicM,MehuysE,BousseryK,SomersA,SpinewineA,BauwensM,GobertM,

ElseviersM

M

and

Vander

Stichele

R

(2011)

Organization

of

the

medication

management

process

in


38/38

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