A new study has raised concerns about the accuracy of packaging of dose administration aids provided to regional aged care facilities.
The study of 42 residential aged care facilities in the Hunter region of NSW detected 297 errors from 6972 packs for 2480 residents -- an error rate of 4.3 per cent of packs, affecting 12 per cent of residents.
The most commonly reported error was a medication missing from a pack (99 occasions). Other incidents included incorrect dosage instructions (32), supply of the wrong strength (32), wrong medication dispensed (12), incorrect labelling (7), pharmacies supplying medication that had been ceased by the GP (37), and medications not delivered to the aged care facility (13).
Errors associated with GPs (i.e. script not supplied, illegible script or chart, failure to chart or communicate change) were behind the error on 79 occasions; however, the pharmacy was implicated in 125 incidents.
Of 12 supply pharmacies involved in the study, no incidents occurred in two pharmacies, and the rate of incidents compared with resident numbers in the 10 other pharmacies ranged from 1.9 per cent to 22 per cent.
The authors suggested the high error rate in pharmacies may arise from inadequate reimbursement for the service.
"We did not examine this problem in greater depth, but the results suggest that packaging needs to be regarded as a worthwhile endeavour rather than a free service," they wrote.
Poor communication among GPs, pharmacists and aged care facility staff was to blame for many of the errors. The authors suggested that electronic communication would bypass the risk of errors that occur with verbal orders or illegible writing, and can be used by all stakeholders.
"Medical computing in residential aged care facilities and its use by GPs is a basic first step. Further developments, with electronic signatures and systems to permit the medication chart to be recognised as a legal prescription, are also required."
Other improvements, including guidelines to address the issue of advance packaging of dose administration aids, monthly audits with both the pharmacist and a registered nurse in attendance, standard use of generic drug names, terminology, abbreviations and symbols in prescriptions and drug charts, are also needed, they said.
The study was published in the most recent
Medical Journal of Australia.