managing and administering medication in care homes
TRANSCRIPT
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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
5Szczepura,WildandNelson,2011
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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7
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
9Szczepura,WildandNelson,2010
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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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.
17VandenBemtetal,2009
18Dillesetal,2011
19Thomsonetal,2009
20Kreckleretal,2008
21Alldred,Barber,Carpenteretal,2009
22Lane,2010
23Alldred,Barber,Carpenteretal,2009
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
25VandenBemtetal,2009
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
30Alldred,Barber,Carpenteretal,2009
31Morrisetal,2004
32Howardetal,2007
33Dillesetal,2011
34Alldred,Barber,Carpenteretal,2009
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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
.
35Szczepura,WildandNelson,2010
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
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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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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
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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.
46Alldred,Barber,Carpenteretal,2009
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
51Alldred,Barber,Carpenteretal,2009
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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.
52Alldred,Barber,Carpenteretal,2009
53Pharmaceutical Journal,2002
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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
54Alldred,Barber,Carpenteretal,2009
55Zimmermanetal,2011
56VandenBemtetal,2009
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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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9.
REFERENCES
AND
FURTHER
READINGS
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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
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BurnhamT(2012)Medicationproblemsofolderpeople:annotatedbibliographyofpublications,
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CareQualityCommission(2010a)Guidanceaboutcompliance:Essentialstandardsforqualityand
safety,London:CareQualityCommission
CareQualityCommission(2010b)Guidanceaboutcompliance:Summaryofregulations,outcomes
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