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Underlying risk factors for prescribing errors in long-term aged care: a qualitative study
  1. Amina Tariq1,
  2. Andrew Georgiou1,
  3. Magdalena Raban1,
  4. Melissa Therese Baysari1,2,
  5. Johanna Westbrook1
  1. 1Centre of Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
  2. 2Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
  1. Correspondence to Dr Amina Tariq, AIHI, Macquarie University, 75 Talavera Road, Level 6 Sydney, NSW 2109, Australia; amina.tariq{at}


Objective(s) To identify system-related risk factors perceived to contribute to prescribing errors in Australian long-term care settings, that is, residential aged care facilities (RACFs).

Design and setting The study used qualitative methods to explore factors that contribute to unsafe prescribing in RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May and November 2011. Participants included RACF managers, doctors, pharmacists and RACF staff actively involved in prescribing-related processes. Methods included non-participant observations (74 h), in-depth semistructured interviews (n=25) and artefact analysis. Detailed process activity models were developed for observed prescribing episodes supplemented by triangulated analysis using content analysis methods.

Results System-related factors perceived to increase the risk of prescribing errors in RACFs were classified into three overarching themes: communication systems, team coordination and staff management. Factors associated with communication systems included limited point-of-care access to information, inadequate handovers, information storage across different media (paper, electronic and memory), poor legibility of charts, information double handling, multiple faxing of medication charts and reliance on manual chart reviews. Team factors included lack of established lines of responsibility, inadequate team communication and limited participation of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors related to staff management and workload included doctors’ time constraints and their accessibility, lack of trained RACF staff and high RACF staff turnover.

Conclusions The study highlights several system-related factors including laborious methods for exchanging medication information, which often act together to contribute to prescribing errors. Multiple interventions (eg, technology systems, team communication protocols) are required to support the collaborative nature of RACF prescribing.

  • Medication safety
  • Nursing homes
  • Communication
  • Process mapping
  • Teamwork

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