Errors in dose administration aid packaging in aged care facilities
An article in the Medical Journal of Australia (edition 3 March) has shown a high rate of incidents and errors in does administration aid (DAA) packaging in regional aged care facilities (RACFs) within the boundaries of the Hunter Urban Division of General Practice.
Each participating RACF audited one DAA for each resident receiving medication between May and August 2006. Registered nurses compared the contents with the medication chart prepared by the general practitioner and recorded any discrepancies as incidents.
A total of 297 incidents were detected from 6,972 packs for 2,480 residents (incident rate of 4.3% of packs and 12% of residents) from 42 participating RACFs. Reasons for incidents included medications missing from a pack (99 occasions), wrong medication dispensed (12), supply of the wrong strength (32), incorrect labeling (7), pharmacies supplying medication that had been ceased by the GP (37), incorrect dosage instructions (32), medications not delivered to the RACF (13).
Recommendations for improvement include: continuing audit and analysis by RACFs; streamlining of communications among GPs, pharmacists and RACF staff; using electronic methods to chart, order and dispense medications; use of generic names as much as possible; development of guidelines for the supply of medication in DAAs.
