Medication management in AL settings is a prevalent and time-consuming process, with a high number of daily medications being given to residents with significant frailty. Because the goal of the study was to examine medications administered, all ordered medications that were dispensed by a pharmacy for UAPs to give to residents were included in the count. This could explain why the total number of medications was higher than previous reports in the literature, because it included such preparations as vitamins and eye drops for comfort. The total did not include additional medications or supplements taken independently by residents. This study represents the first reported use in AL of the standardized observation method developed previously. 25
Using the strict definitions outlined in the protocol, the overall error rate was 28.2%, compared with 19% in hospitals and 34.2% to 40.1% in SNFs.28
When time errors were removed from analyses in all settings, the error rate was 8.2% in AL, 10% in hospitals, and 7.4% in SNFs. Wrong time accounted for the bulk of the errors in AL (70.8%), compared with a 43% wrong-time rate observed in hospitals. Despite the high rate of wrong-time errors, none of these was deemed clinically significant. In other words, staff ensured that time-sensitive medications, such as insulin, were given according to the schedule, but were less rigid about delivering other medications at the appointed time.
The relevance of time is important when comparing error rates with those of hospitals, because AL settings are less regimented and more likely to incorporate resident preferences into care delivery. As other authors have asserted, 28
wrong-time errors can relate to systems issues such as staffing levels and facility policies, factors beyond the control of the person administering the medication. The bulk of the medications given are not time sensitive, and aides face the daunting challenge of administering a large quantity of medications in a short time frame, yet all the settings had policies that medications must be given within 1 hour of the scheduled time. Furthermore, most had standardized morning and evening medication pass times and did not customize the schedule according to resident preference or staff load. Under this scenario, a high number of wrong-time errors is not surprising, and given the lack of clinical significance of the errors observed, is probably not a meaningful indicator of quality. The practice of scheduling so many medications at once creates an artificial compression of time that could contribute to errors. Facility staff and regulatory agencies may consider liberalizing the scheduling of medications in this setting, focusing on clinical relevance, consistency, and resident preferences rather than on an arbitrary time goal. RNs in AL are well positioned to address medication scheduling, taking into account medication parameters (such as with meals), resident preferences, and staff delivery logistics.
None of the observed errors were rated highly likely to cause harm. Two methods were used to evaluate the clinical significance of errors. Using the first approach, four errors were rated as having potential for harm. Using the second approach, three errors were identified as having potential clinical significance, suggesting that the first method is more sensitive to errors, whereas the second provides a more-detailed rating. Two of the three errors rated as having potential clinical significance were unauthorized medications (i.e., not having an order for diazepam and insulin). The most interesting finding regarding clinical relevance was that errors occurred more commonly with higher-risk medications (e.g., insulin, warfarin, furosemide) associated with residents in less stable and predictable conditions. This is consistent with a recent audit of medications most commonly involved in errors in SNFs, implicating the drugs lorazepam, warfarin, insulin, hydrocodone, and furosemide. 33
A recent study of the risk of emergency department isits for ADEs that identified warfarin, insulin, and digoxin as responsible for 33.3% of these visits also supported the findings of the current study. The risk of ADEs leading to an emergency department visit was 35 times as high for these three medications as for medications always considered to be inappropriate according to the Beers criteria.34
Dosage changes, in response to symptoms or laboratory results, are more common with several high-risk drugs involved in errors, such as warfarin, furosemide, and insulin. It is likely that the furosemide and warfarin sodium errors were related to communication problems of getting the changes in dose transcribed or communicated to the person giving the medication. Systems could be improved to expedite communication about changes in regimen between primary care providers, pharmacies, and AL staff to promote timely transcription, ordering, dispensing, and administration. For the insulin errors, the errors were related to sliding-scale doses, which involved adding a standing dose to a sliding-scale dose. Given the low educational preparation of the medication aides, strategies to address mathematical errors could be employed.
There were several limitations to this study. First, the sample was a convenience sample of settings in three states. A larger randomly selected sample would strengthen the study. Because this was a cross-sectional observational study, it was assumed that the errors were one-time errors only, yielding a conservative interpretation of the clinical significance. An important next step would be to determine the rate at which errors are repeated, or not corrected, and to analyze the clinical significance of such oversights. This study did not examine self-administration of medications in AL, a practice of fewer than 20% of residents in the study settings. Future work could examine relative error rates of unlicensed staff versus resident self-administration. Finally, the effect of the observer on error rates is a common concern, although observers who were trained to minimize their effect observed participants in as unobtrusive way as possible during highly familiar routines. The methodologists who developed this approach have examined the effect of the observer and have concluded that there is minimal influence.27
In addition, direct observation as a common approach to measuring quality in long-term care was evaluated previously and the conclusion reached that observations were stable and did not seem to change behavior appreciably.35
In conclusion, this study supports the assertion that medication management is a salient clinical concern in AL, with a large quantity of medications given daily and a high level of resident dependency on staff for this service. UAPs generally do remarkably well with this complex task, given their level of training and preparation. The bulk of the medications are low risk and routine, and the risks appear to be minimal. Several higher-risk medications were identified, with the implication that attention to delivery of these medications should be prioritized to promote targeted prevention. Professional clinical attention, which is in limited supply in AL, could be targeted more strategically to promote optimal care delivery. For example, with the high number of medications ordered, clinicians could focus on high-risk residents and high-risk medications, the appropriateness of the medication regimen, and the efficacy of the pharmacological approaches, particularly for residents with multiple comorbidities.36
Health information technology is limited in AL, particularly linking settings to pharmacies and primary care providers, yet technology could enhance accuracy and timeliness of communication about medication management throughout the process, from prescribing through administering. Nurses in AL play multiple roles and have the potential to enhance the health of the community of residents by identifying residents at higher risk and prioritizing assessment and resident and staff education to promote optimal outcomes from the medication program.