People in care homes are a frail and vulnerable population at particular risk from medication errors, and it is a cause for concern that two thirds of care home residents in this study were exposed to one or more errors. For each event involving prescribing, dispensing or administration of a medicine, there was an 8%–10% chance of an error happening and a 14% chance of a monitoring error. Safety is a systems issue, and we believe this is the first study to consider the whole system of medication use in care homes; our simultaneous collection of qualitative data has allowed us to understand the causes of error and suggest solutions.
The prevalence of prescribing error is similar to that found in primary care21
; administration error prevalence was a little higher than that in hospital22
(and likely to be better than the patients’ adherence if in their own home).23
The prevalence of dispensing errors was three times higher than the rate found in primary care in the UK,24
although that study excluded MDS. Our higher rate predominantly reflected one type of MDS that was difficult to label fully.
Although our study was not primarily designed to identify the prevalence of harm, we saw several errors, particularly monitoring errors, which had caused harm or were likely to. In addition, many errors would reduce the quality of life and ability to function of residents, such as inadequate treatment of pain, of bowels and of breathing.
Limitations to our study include that our sample only contained those willing to be studied (although the acceptance rate of homes was high) and that our home sampling was not random. Judgement of the cause of error was sometimes difficult as there could be conflicting sources of evidence or a lack of evidence; hence, judgements sometimes retained an element of subjectivity. Observation may theoretically have affected the prevalence of administration error, although routine observation has been found to have no effect.11
Staff interviewed will have given accounts affected by hindsight bias; hence, imputations of causality are speculative.
What can be done, and who should do it? As our study shows, there are currently many and varied subsystems that are not being seen in an integrated way. There is now the opportunity for a systems approach to the whole. Since 2008, chief pharmacists of provider organisations and commissioners in England should have the lead role in ensuring safe medication practices are embedded in patient care25
; a significant and pressing agenda for them. An additional system-based solution relates to several of the communication and records problems observed—we would hope these would be ameliorated by programmes in the National Health Service’s information technology programme (NPfIT), such as the Summary Care Record (a brief GP record which can be accessed by others), GP2GP (electronic transfer of patients’ notes between GPs) and the Electronic Prescription Service (electronic transfer of primary care prescriptions). The final system issue is that most primary care is based on patients going to centres of care rather than the other way around. Primary care services that are based on care going to patients need to be commissioned, in order not to disadvantage the home bound.
We suggest the idea of a lead (not sole) GP for each home should be explored. This role would need protected time and associated funding. In addition to caring for patients, they should liaise with other GPs and have responsibility to ensure, possibly by commissioning services, that patients on riskier medicines are appropriately monitored and that all patients’ medication is regularly reviewed by a pharmacist.
Consideration should be given to having one person with overall responsibility for medicines use in one or more care homes. Many pharmacists have the skills and knowledge to undertake this role, and such developments are described in the UK government’s recent proposals for making best use of pharmacists’ expertise.25
Pharmacists supplying homes should ideally know the home, its ways and needs, so that ordering and supply match the home’s (and patients’) needs. The widespread use of MDS unit dose systems, requiring millions of tablets to be repackaged each week, is a vast, unfunded undertaking. It imposes demands on home and pharmacy alike, yet its contribution to safety is unclear and some commissioners discourage its use. The use of MDS drives efficiencies of scale, such as large centralised repackaging units, which in turn leads to the dispensary becoming remote from the customers (home and patient). Research into the effectiveness of MDS is urgently required.
Within homes the use and accuracy of the medication administration record requires constant review. The lack of protocols and adequate staff training remains an issue. Drug rounds are very busy, and often interrupted in the morning, and some medicines should be prescribed for different times to ease this. The commonest administration errors were omissions because the drug was not available, so omissions need to be monitored and ordering, particularly of “as required” medicines, needs to be improved.
We were very impressed by the proportion of homes participating in a study, which was potentially very threatening to them. Several care home managers have told us that patient harm from medication error is their greatest fear and that up to half of staff time can be spent on medication related activities. Given this motivation and resource, we are hopeful of change.
Context: Care homes and the English National Health Service
Care homes may provide 24-hour nursing care (nursing homes), personal care only (residential homes) or a combination. They may be owned by individuals or companies of various sizes, including large private health providers, charities or by the local authorities. Care homes are reviewed against standards by the Care Quality Commission, which is the independent regulator of health and social care in England. Each resident is registered with a general practitioner who provides their medical care and keeps their medical record. When a patient transfers from their own home to a care home, they can elect to keep their general practitioner if he or she is local.
In England, the National Health Service is delivered through 152 primary care trusts, which are responsible for a geographical area of the country, for which they commission healthcare from general practitioners (primary care physicians) who usually work as part of a group practice, pharmacies and others. Pharmacies may be owned and run by a single pharmacist or may be part of a chain; the largest chains are run by international companies. Homes usually obtain their regular supply of medicines for all their residents from one pharmacy.
Repeat medicines are ordered from the GP practice (usually monthly) by the care home staff using the previous 28-day medicine administration record or the repeat medicines slip provided by the GP practice. Generally the GP practice authorises and prints the repeat prescriptions and sends them to the care home for checking. They are then forwarded to the community pharmacy where they are dispensed and delivered to the care home with a new 28-day medicine administration record.