RT Journal Article
SR Electronic
T1 Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people
JF Quality and Safety in Health Care
JO Qual Saf Health Care
FD BMJ Publishing Group Ltd
SP 341
OP 346
DO 10.1136/qshc.2009.034231
VO 18
IS 5
A1 N D Barber
A1 D P Alldred
A1 D K Raynor
A1 R Dickinson
A1 S Garfield
A1 B Jesson
A1 R Lim
A1 I Savage
A1 C Standage
A1 P Buckle
A1 J Carpenter
A1 B Franklin
A1 M Woloshynowych
A1 A G Zermansky
YR 2009
UL http://qualitysafety.bmj.com/content/18/5/341.abstract
AB Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.