Ironclad protocols needed to prevent medication errors

Australia’s Aged Care Quality and Safety Commission has issued a clinical alert following the death of an aged care resident that was directly caused by administration of medications that were not prescribed for them.

The coroner noted the resident’s death was due to a series of systemic errors and a wholesale lack of adequate checks and balances occurring when the service was transitioning from their original paper-based, handwritten medication charts to an electronic medication management (EMM) system.

The national background to the incident is one in which residential aged care services are making the transition from paper-based medication charts to electronic systems of dispensing. While EMM systems are perceived to be safer overall, transferring from one system to another is a high-risk process, as this incident shows.

The residential aged care service employed a local pharmacy they had not used previously to take over the supply of medications to the service and to facilitate the changeover from a paper medication chart system to an EMM system.

The software company providing the EMM system incorrectly transcribed the medications from the resident’s paper chart to the electronic medications chart while assisting the local pharmacy (responsible for preparing the individualised medication packs) to implement the new system.

Subsequently, the general practitioner who signed off/approved the new electronic medication chart did not observe that incorrect dosages and additional medications for that resident were included on the new electronic medications chart.

The residential aged care service’s staff relied on this pre-packed medication and did not crosscheck the EMM chart against the old paper medication chart.

The error that occurred was a duplication of two residents’ profiles; a similarly named resident’s medication list, while being entered into the EMM system, was accidentally added to the chart of the resident who subsequently lost their life after being given that other person’s prescribed medication. The same or similar names are always a red flag when checking, prescribing and administering medications.

System reforms

Following the death, the residential aged care service conducted an internal review using the Department of Health’s Guiding Principles for Medication Management in Residential Aged Care Facilities.

The service implemented the following reforms:

• Medication audits will be conducted at regular intervals and a further audit is conducted with pharmacy staff who attend the site every 4 months.
• Facility staff always check new medication packs against current drug charts.
• Staff will undergo regular and further training on medication administration.
   

In response to the incident, the Commission strongly recommended that there be an effective process involving at least two people independently checking the medication records when changing, updating or transcribing a resident’s medication record/chart.

GPs and prescribers should also be aware of their overarching responsibility in signing either electronically generated or handwritten medication charts, the Commission said. In addition, it is important that residential aged care services conduct regular medication audits reporting to their medications advisory committee, and promptly address any issues detected.

Where possible, services should ensure residents are informed about what medications they are taking — this can provide another layer of safety. Staff, residents and involved family members should also feel empowered to raise concerns or issues about residents’ medications.

The six ‘rights’ of administering medication should be carried out by services every time: the right medication; the right dose; the right person; the right time; the right route; and the right documentation. Errors regarding these six fundamentals of medication management were frequently identified in analysis of medication-related complaints to the Commission, indicating that more caution is required.

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