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Tariq, Amina, Georgiou, Andrew, Raban, Magdalena, Baysari, Melissa, &Westbrook, Johanna(2016)Underlying risk factors for prescribing errors in long-term aged care: aqualitative study.BMJ Quality and Safety, 25(9), pp. 704-715.
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https://doi.org/10.1136/bmjqs-2015-004589
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Title: Underlying risk factors for prescribing errors in long term aged
care: A qualitative study
Amina Tariq1, Andrew Georgiou1, Magdalena Z Raban1, Melissa Baysari1, 2, Johanna
Westbrook1
1 Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Australia
2 Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Sydney Australia
Correspondence should be addressed to Amina Tariq at the Centre for Health
Systems and Safety Research, Australian Institute of Health Innovation, Level 6 75
Talavera Road, Macquarie University NSW 2109, Australia. Tel: +61 (0)2 9850 2481.
Fax: +61 (0)2 8088 6234. (email: [email protected])
WORD COUNT: 4700 words (excluding abstract, tables and references)
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Abstract
Objective(s)
To identify system-related risk factors perceived to contribute to prescribing errors in
Australian long term care settings i.e. residential aged care facilities (RACFs).
Design and Setting
The study used qualitative methods to explore factors that contribute to unsafe prescribing in
RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May
and November 2011. Participants included RACF managers, doctors, pharmacists and RACF
staff actively involved in prescribing-related processes. Methods included non-participant
observations (74 hours), in depth semi-structured interviews (n=25) and artefact analysis.
Detailed process activity models were developed for observed prescribing episodes
supplemented by triangulated analysis using content analysis methods.
Results
System-related factors perceived to increase the risk of prescribing errors in RACFs were
classified into three overarching themes: communication systems, team coordination and staff
management. Factors associated with communication systems included limited point of care
access to information, inadequate handovers, information storage across different media
(paper, electronic and memory), poor legibility of charts, information double handling, multiple
faxing of medication charts and reliance on manual chart reviews. Team factors included lack
of established lines of responsibility, inadequate team communication and limited participation
of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors
related to staff management and workload included doctors’ time constraints and their
accessibility, lack of trained RACF staff and high RACF staff turnover.
Conclusion
The study highlights several system-related factors including laborious methods for
exchanging medication information, which often act together to contribute to prescribing
errors. Multiple interventions (e.g. technology systems, team communication protocols) are
required to support the collaborative nature of RACF prescribing.
Key words: long term care, residential aged care facilities, prescribing,
communication, system errors, medication errors
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Introduction
Concerns about prescribing safety in long-term aged care facilities have been raised
worldwide by policy makers, academic researchers, the media and residents’ families.1-12
To
reduce preventable harm, safe prescribing in aged care facilities requires consideration of
residents' total needs in order to mitigate cognitive and functional deterioration.1-3
Various
studies exploring prescribing safety in long-term aged care facilities report a higher rate of
prescribing errors compared to hospitals.7, 14, 15
Australian long-term aged care facilities also
report a high incidence of polypharmacy with residents averaging seven to ten medications
each.16, 17
One US study found 40% of long term care residents regularly received at least
one inappropriate medicine,18
and in another study, 17% of residents had daily doses of
antipsychotic drugs exceeding recommended levels.19
In Australia, long-term aged care facilities which provide personal as well as nursing care for
residents are known as residential aged care facilities (RACFs). In RACFs, safe medication
delivery is reliant upon the coordination of activities across three key domains: i) general
practitioners (GPs), who practice offsite but are responsible for prescribing; ii) community
pharmacies, where medications are dispensed and packed into unit dose blister packs; and
iii) RACFs, where medications are administered.20
In addition to these three domains, RACFs
need to coordinate with hospitals, medical specialists and allied health staff who also provide
services to residents on a regular basis.21
Human errors in such dispersed and dynamic
contexts are described as a property of the system as a whole, rather than an individual’s
responsibility.22-24
Individuals might initially appear responsible for errors; however,
investigation into these errors usually uncovers a wide range of system-related factors that
contribute to the error.25, 26
Designing or implementing interventions that are effective in improving prescribing safety
requires identification and consideration of the system-related factors that contribute to
medication error occurrence.29-31
Existing medication incident reporting systems in RACFs are
poorly designed and focus on individual responsibility for errors.32
They have limited capacity
to improve safety because they only identify factors that are proximal to the incident.32
While a
single action or omission by a GP may appear as the immediate cause of a prescribing error,
investigations often ignore the latent weaknesses in the working environment that promote or
permit errors.25, 33
A systems approach recognises that the likelihood of an unsafe act is
influenced by the nature of the task and local working conditions.33, 34
Few studies have examined prescribing errors in long term aged care settings and fewer still
have investigated potential causes of these errors.15, 27,28
Barber et al.,15
prospectively
analysed errors and their potential causes across different stages of medication management
in UK aged care homes, and identified communication(written and verbal), between the
nursing home, GPs and pharmacy as a major contributor to medication errors. In 2008, a
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broad review of 40 studies exploring the incidence and types of medication errors in aged
care settings reported that despite widespread recognition of the potential role of system-
related factors in increasing the risk of medication errors, little attempt had been made to
identify these system-related factors.27
In this qualitative study, we aimed to conduct an in-
depth examination of RACF prescribing processes to identify specific system-related factors
perceived to contribute to prescribing error risk in RACFs and pinpoint interventions that could
potentially reduce that risk.
Materials and Methods
Setting
The context of this research is RACFs in Australia, which provide accommodation, nursing
care, domestic services (such as laundry, meals and cleaning) and support for personal tasks
(activities of daily living) for residents.4 Prescribing errors in health care settings are generally
defined as “…a prescribing decision or prescription writing process, [where] there is an
unintentional significant (1) reduction in the probability of treatment being timely and effective
or (2) increase in the risk of harm when compared with generally accepted practice”.13
(p. 235)
A convenience sample of three RACFs in metropolitan Sydney, Australia participated in the
study. The selected sites were part of a large non-profit organisation. Participating sites had
populations comprised of a mix of residents classified as either: a) low-level care that covered
the provision of suitable accommodation and related living services (such as cleaning, laundry
and meals), as well as personal care services (such as help with dressing, eating,
medications and toileting); and b) high-level care that covered accommodation and related
living services, personal care, nursing care and palliative care. The RACF care staff members
are required to achieve competencies (as per the established organisational criteria) to
become eligible to administer medications. At the organisational headquarters, the quality
management team is responsible for monitoring the quality of the care services provided by
the facilities. The quality manager is supported by a qualified team including a registered
nurse (RN) as well as an administrative assistant who organises and manages information.
GPs prescribe on residents’ paper medication charts maintained at the RACFs for medication
administration (Figure 1). In addition, they are required by legislation to provide separate
prescription for every medication to allow dispensing by community pharmacies. The chart
contains different sections for prescribing regular medications; short-term medications (e.g.
antibiotics), PRN (pro re nata (when required)) and non-packed medications (e.g. eye drops).
GPs are required to rewrite the whole chart every six months. The charts are faxed to the
community pharmacies along with the prescriptions for every new medication order, altered
orders or discontinuations.
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Figure 1: A Resident's Medication Chart
Participant Recruitment
The study participants were purposively recruited, based on their involvement in medication
management processes at the sites. Ethics approval was obtained by the University of New
South Wales, Sydney, Australia. Table 1 presents the details of the sites and participants.
Informed written consent was obtained from all study participants prior to data collection.
Data Collection
Data were collected using direct observations and semi-structured interviews supplemented
with detailed artefact analysis to obtain context-rich information. Direct observations within
RACFs were conducted of all activities related to prescribing (e.g. verbal communication,
GPs’ reviewing residents’ information and prescribing). Prescribing-related activities that
occur outside RACFs were not included. One of the authors (AT) collected observational data
over seven months. The observer was a trained human factors analyst with extensive
experience in conducting qualitative research.
Field notes and photographs of the artefacts were a prime source of data. Artefacts in this
study encompassed “any artificial device designed to maintain, display, or operate upon
information in order to serve a representational function”.35
(p.17) All the key artefacts used in
the prescribing process, namely medication charts, discharge summaries, doctors’ notes and
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electronic progress notes were analysed to determine their content, physical form,
representations used (e.g. abbreviations) and inter-dependencies (e.g. both medication charts
and residents’ medical notes to be updated to reflect the actual change in medication and
reasons for the change, respectively).
Observations were conducted during day shifts (7:00-15:00) on weekdays, as site managers
indicated that doctors’ visits and prescribing-related activities are most intense during these
times. During observations, participants were asked specific questions to clarify information
about the activities performed and the related use of artefacts. These short-duration
purposive field interviews were distinguishable from the detailed semi-structured interviews in
that they were conducted in the immediate context of the activities being performed. These
interviews were undertaken opportunistically rather than by prior agreement and were
transcribed into the field notes. One of the researchers (AT) also attended two medication
advisory committee (MAC) meetings. These bimonthly meetings aimed to provide a platform
for GPs, pharmacists and RACF managers to discuss medication management issues.
RACFs (usually up to five sites) were grouped together based on their location and sharing of
services from the same community pharmacy. The MAC meetings were scheduled at one of
the RACF sites included in the group, for a duration of one to two hours during working hours.
To gain an understanding of the issues raised in MAC meetings, minutes of the last five
meetings held for the study sites were also reviewed.
As the prescribing process components were distributed over time and space; it was not
possible to capture the complete process by using observations alone. Semi-structured
interviews enabled identification of system-related factors perceived by the participants to
contribute to error occurrence. Interviews were conducted at the RACFs (Table 1). The
interview guide was informed by literature suggesting approaches to examination of system
factors in health care settings.24-26
A pilot interview with one RACF manager and a pilot two
hour observation session at one site prior to data collection were conducted. The participants
were asked questions on a range of issues relating to RACF prescribing processes, including
examples of common prescribing errors, information exchange, artefacts, and coordination
with other professionals involved in the process. They were prompted to discuss any issues
they experienced during the prescribing processes. Selected members of the organisation’s
quality management team were also interviewed to gain an understanding of quality concerns
relating to prescribing processes. All interviews were audio-taped, professionally transcribed
and verified.
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Table 1: Data Collection Summary
Residential aged care facility - Site A
Site Characteristics
Number of residents: 58 (low care=30, high care=18)*
Staff distribution:1 care manager (also the nursing consultant), 1 deputy care manager, 8 personal care workers, 8 staff members (qualified for medication administration)
Number of doctors: 6 †
Number of servicing pharmacies: 2
Observations
Sample: 3 doctors, 1 care manager, 1 deputy care manager, 7 staff members, 1 pharmacist, 1 pharmacy technician
Total observation time: 28 hours (prescribing episodes=9) ‡
Average observation time per session: 4.5 hours
Interviews
Sample: 1 doctor, 1 care manager, 1 deputy care manager, 3 staff members
Average time per interview: 25 minutes
Residential aged care facility - Site B
Site Characteristics
Number of residents: 46 (low care only) Staff distribution: 1 care manager, 1 deputy care manager, 1 nursing consultant (part-time), 6 personal care workers, 8 staff members (qualified for medication administration)
Number of doctors: 5†
Number of servicing pharmacies: 1
Observations
Sample: 4 doctors, 1 care manager, 1 deputy care manager, 1 nursing consultant, 8 staff members, 1 pharmacist Total observation time: 26 hours (prescribing episodes=8) Average observation time per session: 4 hours
Interviews
Sample: 1 care manager, 1 deputy care manager, 1 nursing consultant, 3 staff members Average time per interview: 29 minutes
Residential aged care facility - Site C
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Site Characteristics
Number of residents: 26 (low care only) Staff distribution: 1 care manager, 1 deputy care manager, 1 nursing consultant (part-time), 5 personal carer workers ,4 staff members (qualified for medication administration) Number of doctors: 4 Number of servicing pharmacies: 1
Observations
Sample: 2 doctors, 1 care manager, 1 deputy care manager, 1 nursing consultant, 4 staff members, 1 pharmacist Total observation time: 20 hours (prescribing episodes= 6) Average observation time per session: 4.5 hours
Interviews
Sample: 1 deputy care manager, 1 nursing consultant (also serves site B), 2 staff members
Average time per interview: 25 minutes
Quality Management Team at Headquarters
Interviews
Sample: 1 quality manager, 2 members of the quality management team Average time per interview: 35 minutes
* Low-level care covered the provision of suitable accommodation and related living services as well as personal care services. High-level care covered accommodation and related living services, personal care, nursing care and palliative care.
† Visiting on a regular basis ‡ A prescribing episode was the time during an observation session where a doctor visited the RACF site and added or discontinued medications, wrote prescriptions or renewed medication charts for one or more residents
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Data Analysis
The data collected consisted of detailed information on the activities performed as part of the
RACF prescribing processes. To facilitate in-depth examination, analysis was undertaken by
initially synthesising the qualitative data to develop maps of observed prescribing scenarios
using the business process model and notation (example scenarios presented in Figure 2 and
3).36
These process maps enabled the: 1) Detection of common patterns of prescribing
related activity across different scenarios, and 2) Identification of inter-linked issues involving
tasks, people and artefacts. The examination of artefacts used during prescribing provided
insight into the artefacts’ context and purpose. Further, we used triangulated content analysis
to derive themes relating to system-related factors underlying errors.37
NVivo software was
used to support qualitative analysis.38
The interview guide was employed in the initial stage of
analysis to form broad, macro-codes and a taxonomy of system-related factors under which
open-coded content could be classified. One author performed the initial open coding of the
data, which was reviewed and modified by the research team. Data were iteratively analysed
in research team meetings (n=10). Revision and finalisation of themes was achieved by
consensus. Member checking of results occurred through follow-up interviews with
participants. A focus group with participants (quality manager, site managers and the nursing
consultant) was conducted at one of the study sites to review the process maps and findings
from the observational data.
Results
We conducted a total of 74 hours of observation (average observation session 4-4.5 hours)
across three sites between May and November 2011. During these sessions we observed 23
unique prescribing episodes. (i.e. where a doctor visited the RACF site and added or
discontinued medications, wrote prescriptions or renewed medication charts for one or more
residents). We interviewed 25 participants, including RACF managers, nursing consultants,
RACF staff members involved in prescribing related activities and doctors. The observations
and interviews were conducted until theoretical saturation was reached, a point at which we
were no longer gaining new information from subsequent participants.
Prescribing errors and associated themes
Table 2 presents examples of different types of prescribing errors described by the
participants during interviews. Errors included omission of a regular medicine, incorrect or
missing dosage details and mismatches between a medication order on the chart and the
associated prescription. The triangulated analysis produced three over-arching themes, with
contributing sub-themes, describing system-related factors related to the occurrence of
prescribing errors. The most prevailing theme was communication systems. This theme
reflected the effectiveness of systems in place to allow the exchange of information between
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GPs, RACF staff, community pharmacists and hospitals. This included both written and verbal
communication. The second theme related to how each of the different professionals (GPs,
RACF staff and pharmacists) worked as part of a team. The final theme encapsulated the
factors associated with appropriate management of staff and workload issues in relation to
medication management. We noted interactions between the thematic categories, such as
communication and staff management factors (Table 2). Participants often cited multiple
factors that contributed to the occurrence of a single error. For example, as discussed below,
the case of an omission of Parkinson’s drugs for one of the residents was associated with
both communication system factors and team factors.
Table 2: Examples of prescribing errors Example Prescribing Errors
We also had a case a little while ago where the doctor re-wrote the chart and left off a lady’s Parkinson drugs...it wasn’t picked up for a couple of days and when you actually looked at the chart and you looked at the medication pack, they matched. The fact that he left off the drugs we would never have picked up until the lady of course began to get some difficulty with her walking”(Interview- Quality Team Member)
“The Gastrogel [prescribed by doctor], doctor has put ten to twenty mg, we would never have ten to twenty milligrams, it’s either ten or twenty [be]cause our care staff can’t make a clinical decision… We never have variable doses in this [be]cause it’s ultimately then the pharmacist who’s choosing to pack it” (Interview - Care Manager, site C)
“He obviously just hasn’t written the alternate [days] Or like written three times a week [on a renewed chart]. Which does happen? Sometimes when they’re [doctors] in a hurry” (Interview - Care Manager, site A)
“Doctor might order something on the medication chart and then he may say something different, perhaps he might say for instance have it once a day and then [on] the medication chart he might say twice a day”(Interview- Care Manager, site B)
“Doctor has put seventeenth to the twenty-fourth [for the first course of antibiotics] but then twenty-fourth to the first so it could end on the twenty-third then the twenty-fourth [for the second course of antibiotics]...I prepare the signing sheets by putting dates on it as the girls will – they’ll get these two orders [at the same time] which are of different doses” (Interview - Deputy Care Manager, site B)
“Sometimes the script doesn’t match the chart for lots of reasons because doctors forget or they write one thing on our chart and something else on the script”(Interview - Quality Manager)
“What’s interesting about this [a resident’s medication chart] is there’s no doctor’s signature so that’s actually a legal thing so I’d be actually saying who gave it and where’s the doctor’s signature?” (Interview - quality team member)
Theme 1 - Communication system factors
Our findings revealed that existing communication systems made prescribing a cumbersome
process. GPs often found it difficult to access a resident’s background information at the point
of care. As depicted by the scenario in Figure 2, the information for prescribing decisions was
distributed across different artefacts (e.g. medication charts, progress notes etc.) and storage
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media (paper, electronic and individual’s memory). The accuracy, relevance, completeness
and timeliness of the information during prescribing relied heavily on manual procedures.
Hospital discharge letters were often unclear and incomplete. Figure 3 illustrates a situation
where a GP ceased a medication on which a resident was discharged from hospital. The
discharge summary did not list the reason for prescribing the medication and the GP had to
make a decision based on his/her experience with the resident.
When not in attendance at the RACF, GPs relied on RACF staff to give them all the required
information verbally on the telephone.
“When you talk to doctors [on telephone] they naturally don’t have sort of access – they don’t have
access to the information so you give them updates on some of that – because they don’t have
medication charts or things in front of them” (Interview - nursing consultant)
Interviews with the RACF staff identified that the nature of this information exchange varied by
staff or shift. For instance, it was reported that during night shifts, managers were absent and
the accuracy and quality of information provided could be incomplete. As indicated by the
scenario in Figure 2, GPs complained about RACF staff contacting them or requiring urgent
visits, yet subsequently being unable to explain why they had been called.
Analysis identified poor legibility of the medication chart as a major communication issue.
“Doctor [X] been in to see [the resident] and put him on a course of prednisone and often you can’t
read the writing. I’ve got used to it but it’s still hard” (Interview - deputy care manager, site A)
“It’s like insulin now they have to write the units. You can’t just put 8u’s because sometimes
people’s u’s look like zeros so they have to write 8 units, U N I T S” (Interview - nursing consultant,
after prescribing episode)
Artefact analysis revealed that the medication charts often exceeded 4-5 pages with
numerous changes and omissions. GPs frequently needed to renew charts which required
them to review and rewrite the complete list of medications. Participants reported that this
often resulted in errors, such as omissions (Table 2).For offsite prescribing activities (e.g.
correction of a resident’s chart), the exchange of information relied on faxing residents’
medication charts between the GP and RACFs.
“If doctor has done a mistake in writing the medication chart and they cannot come to fix it I fax
them the medication chart to get it corrected. They fax it back to us and I paste this chart in the
medication charts folder and next time doctor comes in they can write on the original chart and we
can then remove the fax copy” (Interview - deputy care manager, site C)
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The exchange of residents’ medication charts using a fax was also a common practice in
scenarios which required doctors to prescribe medications (e.g. antibiotics) when offsite. This
resulted in the cluttering of medication charts with scribbles and multiple fax pages with no
page numbers stapled to residents’ medication charts.
“If something happens, say for argument’s sake I’m a nurse and I could ring up a doctor and say,
look [resident X] looks like she’s got cellulitis or her wound looks infected, they might say look I’ll
put them on a course of antibiotics, I would fax chart over to them and they would then write it, fax
it back and then I would actually have to stick it in there. So that sometimes you will see that the
charts have stuck in pages.” (Interview - quality team member)
Double handling of information was visible throughout the process. GPs were required to
document notes in residents’ files as well as maintain their own notes.
“They [doctors] have their own files in the surgery and they update those when they visit here. Well
you would hope that they would do” (Interview - nursing consultant)
Writing medication orders on the chart as well as the paper prescriptions for the community
pharmacy resulted in inaccuracies due to mismatch of information between the two.
“I’ve actually contacted the doctor [using the telephone] in regards to that prescription; it is different
than what medication chart says so needed to confirm which one is correct” (Interview - deputy
manager, site B)
Chart auditing was infrequent due to the time and resources required. This made it difficult for
community pharmacies and doctors to verify and correct discrepancies in a timely manner
and errors may result because of the mismatch between charts and medication packs.
“Three years ago it was, [quality team manager] and I physically actually audited twelve hundred
charts. We did medication audits for days and days and days... sometimes there were things in the
[medication] pack that weren’t on the chart or things in the chart that weren’t in the pack” (Interview
- quality team member)
Theme 2 – Team coordination factors
Factors associated with team coordination included dispersion of responsibility, inadequate
team communication and failure of GPs to attend MAC meetings. The responsibility for safe
medication management in RACFs was distributed between GPs, pharmacists and RACFs.
Although the different stages of the medication process (prescribing, ordering, dispensing
etc.) were linked, each stage was carried out in isolation from the other. GPs prescribed
without direct contact with pharmacy, and without being present to observe the consequences
of the medication administration. Individuals attempted to do their best, but in an
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uncoordinated way and without appropriate understanding of the constraints of the system as
a whole.
“The fact that he [doctor] left off the drugs we would never have picked up until the lady of course
began to get some difficulty with her walking, which is what happened. But in that case the GP
said that’s your [RACF’s] problem. Well it’s not our problem because you’re [GP] responsible for
filling out this chart... The staff doesn’t have to check that you’ve done the right thing... Now the
pharmacist should have twigged, hey this person’s suddenly missing Parkinson’s drugs, how
come? But then as a pharmacist said to me, if we did that with every chart that came across our
desk, we would spend all day every day saying Doctor X did you mean to not do it. So it’s not
really the pharmacist’s responsibility either” (Interview - quality team member)
MAC meetings were identified as the only collaborative discussion forum which provided an
opportunity for RACF managers, community pharmacists and GPs to discuss issues related
to residents’ medications. GPs were absent in the observed MAC meetings, which inhibited
team level understanding of the demands and constraints faced by GPs during prescribing.
“MAC meeting usually it could be bimonthly or they could be monthly. Because you’re depending
on the GPs if they will come and a lot of times GPs won’t so depending on when the pharmacist
will come” (Interview - care manager, site A)
Further the RACFs had no formal procedure to record prescribing errors, which limited the
capacity of the team to collectively reflect and learn from errors.
“At the moment prescribing errors are not recorded formally. They are not part of the key quality
indicators (KQI)” (Interview - quality manager)
Theme 3 - Staff management factors
Factors associated with appropriate management of staff and workload also appeared to
increase the risk of prescribing errors. The services offered by GPs were variable as some
visited regularly while others visited only if requested or in cases of emergency.
“Some doctors will come only when they’re [residents] sick and that’s a bit painful” (Interview -
deputy care manager, site B)
Limited timely access to locum GP services including after-hours services was also identified
as a potential factor.
“They’re [locum doctors] contacted as they’re needed to be contacted and we do have an
after-hours service which can be accessed by phone only. There’s only a handful of them
14 | P a g e
really, most of them belong to [service provider X] and [service provider Y]”. (Interview-deputy
care manager site, C)
The requirement to proactively arrange locum doctors to cover for regular GPs when absent
for long periods of time was viewed as a barrier to seamless or uninterrupted prescribing
processes.
“Doctors are busy. And you can appreciate it but if they can’t do it, they need to let us know
they can’t do it. Or if they go on holidays for like three months to let us know. Otherwise there
is no one to relieve them… they [residents] need a contact or a covering doctor. So that’s
something that we’re working on” (Interview- nursing consultant, site B,C)
During observed prescribing episodes, GPs frequently mentioned time constraints. RACF
staff also identified inadequate access to GPs and short availability times as barriers to safe
prescribing.
“They’re busy, doctors not reliable, you keep calling, you [are] waiting for them and, they can
ring and say “Look I’m really busy, maybe another day?” (Interview - deputy care manager,
site C)
Both GPs and RACF managers mentioned limitations in staff skills and lack of knowledge to
support GPs during prescribing.
“Staff do not understand what I am saying to them or asking for” (GP to RACF manager
during prescribing)
“Some people [RACF staff members] may be illiterate and so – and again it’s their
comprehension of English and what do they understand..... Without that sort of underpinning
knowledge, it’s very difficult because they don’t understand why it’s important for someone
with Parkinson’s to have their drugs on time and what happens to them if they don’t”
(Interview - care manager, site A)
The participants also identified staff shortages in RACFs and high staff turnover as factors
that affected the execution of medication tasks.
“It’s a continuous education thing because you’ve always got new staff, [staff is] fairly mobile
so you find that you’ve always got new staff and you need to do their training and education”
(Interview - deputy care manager, site B)
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A shortage of registered nurses (RNs) and delegation of medication tasks to carers was also
viewed to be a factor increasing dependence on GPs to ensure accuracy and completeness
of prescribing orders.
“It’s very difficult to get RNs to work in aged care so we use them to oversee the clinical stuff, we
want them to be looking at wounds and education and care planning and all those sorts of things”
(Interview - quality team member)
The shortage of RNs was also evident from one RN working as a nursing consultant across two
study sites, since the care managers at those sites were not RNs
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Figure 2: Prescribing episode example 1- General Practitioner (GP) visits RACF following an urgent request to attend a resident from the RACF
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Figure 3: Prescribing episode example 2- General Practitioner (GP) visits RACF to examine a resident discharged from hospital
Discussion
This study involved an in-depth examination of prescribing processes to identify latent
system- related factors identified as increasing the risk of prescribing errors in long term aged
care facilities. The identified system-related factors were classified into to three overarching
themes: communication systems, team coordination, and staff management. To collectively
address identified system-related factors, multifaceted strategies are required.
The most significant perceived risk factors were associated with communication systems. We
found that the antiquated prescribing processes in RACFs involving paper-based medication
records, double handling and faxing increased risk of prescribing errors. To address double
handling of medication charts and prescriptions, the Australian government has been piloting
a standardised national medication chart for RACFs since 2012.39
This chart will allow
dispensing for most medications, eliminating the need of prescriptions, therefore addressing
the risks associated with double handling. However, the new chart will not address the array
of other issues identified in this study which include legibility problems, offsite communication
with GPs and information transfer during transitions across different healthcare settings (e.g.
hospitals).38
Shared electronic medication records could enable GPs and community
pharmacists to remotely access residents’ records, offer electronic decision-support (e.g.
alerts on accidental omissions), incorporate mandatory data fields and reduce legibility
problems.40, 41
The implementation of the Australian national personally controlled electronic
health record is in its nascent stages and currently does not include a medication record.42
However future developments may enable shared medication information transfer.42
RACFs in Australia, when compared to health care settings (e.g. hospitals), are in the early
stages of adopting technology-based interventions to support medication management
processes.43, 44
This provides an opportunity to learn from the experiences of the
implementation of these interventions in health care settings, such as hospitals and GP
practices. Electronic medication management systems in Australian hospitals have been
shown to reduce prescribing errors by more than 50%.45
However, studies evaluating
implementation of technology interventions in health care organisations have shown that
failure to address the socio-technical requirements of these complex interventions increases
the likelihood of unintended consequences, encourages adoption of workarounds and
elevates risks to patient safety.46-48 The challenge in aged care is that a single organisation
providing aged care receives services from a number of GP practices, community pharmacies
and hospitals. Though these providers each independently often have electronic systems,
currently these systems are unable to communicate with each other.49
Our study has shown
that communication between settings is a fundamental element of RACF prescribing
processes. Electronic systems that work in isolation, or are designed for one setting only, can
aggravate risks such as information duplication. For health informatics researchers and
system designers, the challenge is to develop, implement and evaluate participatory design
methods that encompass involvement of all groups of users in the design of these systems.50-
53
Technology offers only a partial solution to the identified problems. Our findings emphasise
that technology-based interventions alone cannot address all system-related factors identified
in the study. The existing prescribing processes are driven by human resilience, where
participants compensate for missing, inaccurate and incomplete information through follow-up
with the team members concerned.54
A salient example of this included GPs ceasing a
medication prescribed for a resident while in hospital because the discharge summary had no
information about why the medication had been prescribed. However, we also identified team
and staff factors such as dispersion of responsibility, the short time availability of GPs and a
shortage of full-time RNs, which limit the capacity to exercise resilience. The consequence of
these system risk factors was prescribing errors, like missed medications that took up to 48
hours to be identified. To foster a safe prescribing environment it is vital to make the causes
of errors visible to those working in the system.53-55
Importantly, this should emphasise factors
contributing to errors and the establishment of a system to target these factors.55
Critically, in
our study sites, there was no formal process for error reporting or investigation.
We identified the distributed responsibility associated with the medication process to be a
significant problem. This problem was also reported in a 2009 UK study which explored the
prevalence and causes of medication errors in 55 care homes. That study identified an
absence of holistic responsibility for the safety of the medicines system as a major cause of
medication errors.15
A more recent study explored health providers’ views on barriers to
optimal antibiotic prescribing in Australian RACFs and found that distributed responsibility and
logistical issues such as limited availability of doctors hinder optimal antibiotic prescribing in
RACFs.56
One avenue is for GPs to participate in multidisciplinary initiatives like medication
advisory committee (MAC) meetings to convey the problems they face during prescribing.
However, time constraints and lack of incentives are the issues to be addressed to improve
GPs’ participation in these multidisciplinary initiatives. Improving the financial arrangements
for multidisciplinary initiatives and offering GPs the opportunity to engage in these meetings
remotely via teleconferencing (to address time constraints) may increase their participation.
The shortage of skilled nursing staff and inability to undertake regular medication audits at the
RACFs were safe prescribing risks identified. Enhancing the role of community pharmacists in
regular review and continuous monitoring of medications can facilitate the minimisation of risk
of prescribing errors. The Australian government funds pharmacists to provide collaborative
medication reviews with the GP for RACF residents, as well as Quality Use of Medicine
services to facilities.57
One medication review per resident is allowed per year, (excluding
where there is a change in the patient’s condition or medication), limiting their impact on
regular medication management issues faced by facilities. The Quality Use of Medicines
services provided by pharmacists to facilities include medication audits, education and
contributions to the MAC, and should assist in addressing some of the factors identified in this
study. Funding for these services only became available in the year of the study. Successful
implementation of these interventions on a large scale is dependent on teams which can work
collectively.58, 59
Simply mandating that interventions such as MAC meetings or collaborative
should be implemented, in the absence of any other strategies to ensure their adequate
implementation, is unlikely to be effective.
The staff management factors also highlight the need to introduce programs that develop
skills of RACF staff to proactively identify, assess and communicate issues which relate to
prescribing safety. Examples of these include developing skills on how to proactively seek
information across different settings (e.g. from hospitals, in the case of incomplete discharge
summaries) and how to perform active information review and handover (e.g. reviewing
charts immediately after prescribing, generating resident status reports prior to GP visits).
Formal quality improvement strategies that include development of communication tools and
training programs for RACFs staff are vital for individual skill development, organisational
learning and improving residents’ safety. The INTERACT II program in the USA is one such
example which provides a multitude of communication tools and strategies to enhance an
aged care facility’s ability to identify, evaluate and manage residents’ conditions before
residents require hospital transfer.60
Implementation of such programs encourages inclusion
of systems thinking approaches into training and practice of the care staff involved in
delivering care to residents.61
The factors identified in this study are based on observations and self-reports, which cannot
be regarded as definitive. One obvious limitation was the opportunistic choice of RACF sites.
The limited participation of GPs in the semi-structured interviews prevents conclusions
regarding their perceptions of prescribing issues. Nevertheless, we believe that the results
raise important issues requiring action, particularly given the scant research evidence about
medication safety in RACFs. Further empirical research to test the relationship between
different factors and types of prescribing errors in RACFs is warranted. While the study was
conducted within the under-researched context of residential aged care, the findings have
potential for application in collaborative health care settings. This research provides an
important basis from which to progress knowledge about system-related factors in
collaborative health care settings such as RACFs and to analyse their impact on aspects of
care delivery, medication management in this case, which are intrinsically linked to residents’
safety.
Conclusions
The study highlights several system-related factors which often act together to contribute to
the occurrence of prescribing errors, including antiquated and laborious methods for
exchanging information, dispersion of responsibility and shortage of skilled nursing staff at
RACFs. The study offers insights into the multi-factorial nature of causes underlying
prescribing errors in RACFs. To collectively address these issues, multifaceted interventions
comprising both technological and human elements are required. The complexity of
medication management in RACFs and associated system–related factors indicates a high
risk prescribing environment which has largely been unrecognised as such. Continuous
learning from system failures can minimise risk of prescribing errors occurring.
Competing Interest
The author(s) declare that they have no competing interests.
Acknowledgements
This study was funded by the NHMRC program grant ID No. 568612 which aimed to examine
patient safety across different health sectors in Australia. The program grant was
administered by Australian Institute of Health Innovation (AIHI). We thank RACF sites for their
participation and collaboration in this study.
Figure 1: A Resident's Medication Chart
Figure 2: Prescribing episode example 1- GP visits RACF on urgent request
Figure 3: Prescribing episode example 2- GP visits RACF to examine a resident discharged
from hospital
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