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Drug rounds must be protected in care homes to cut high error rates

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Nurses and care assistants working in care homes must be protected from interruption during drug rounds to reduce the “serious safety issue” posed by high error rates, according to the authors of a UK study.

Nine out of 10 care home patients are regularly exposed to drug administration errors, with half deemed to be serious mistakes, according to the research by the universities of the West of England and Warwick.

The authors, who assessed 13 residential and four nursing homes across England, said the major causes of drug administration errors were lack of time and interruptions, rather than lack of training.  

All drug rounds for 345 older patients were monitored in “real time” over three months using a new barcode medication administration system. The system identified when a potential mistake was about to be made, alerting the nurse or care assistant so that an error was averted.

The authors said 90% of residents were exposed to at least one error during the study, with the most common being the giving of drugs at the wrong time – especially attempts to give medications supposed to be given every four hours too early.

However, 52% of residents were exposed to a serious error such as attempting to give the wrong medication to the wrong patient or a medication that had been discontinued. The serious error rate was similar between the two types of care home.

The study found nearly all staff identified “interruptions during round” as a contributory cause for administration errors, and half highlighted being “stressed” or “under pressure to complete the round”.

Study author Deidre Wild, a senior resarch fellow at UWE, told Nursing Times both staff and managers needed to be more aware of the “high level of risk of medication error” that residents were routinely exposed to and “greater effort needs to be made to protect staff undertaking medication rounds from other work demands”.

Ms Wild added that the findings highlighted the potential for increasing patient safety by using technology such as that used in her study.

She said care staff in nursing homes might be able to use it to safely deliver more simple medications, so registered nurses had more time for higher level nursing activities. But she warned: “This should not be perceived as an opportunity to reduce valuable registered nursing time in favour of employing more care staff at less cost.”

The study is published online in the journal BMC Geriatrics.

  • 10 Comments

Readers' comments (10)

  • It's interesting that nothing has been said about staffing levels in these homes. When I first qualified and worked in a nursing home there were 2 qualified nurses in the unit. This appears in some homes to have been cut to one nurse per unit. That means more time is needed to administer medication, leaving less time to carry out other nursing tasks (including paperwork). All nurses know that the administration of medication requires concentration. If a job that was previously shared between 2 nurses is done by only 1 then of course it stands to reason that there will be more errors made, due to the nurse becoming tired and stressed (thinking no doubt of all the other jobs he/she has still to do).

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  • The ordering and delivery systems for drugs in old peoples' homes is so complex it can take a qualified nurse up to half of an eight hour shift per week to check the stocks, do the ordering, renew prescriptions and take delivery of the stock. This is a lot of time in facilities which are short staffed and where the nurse has to carry out much other routine and more urgent care as well as multitasking. It also requires considerable concentration to prevent errors and carries responsibility for the safety of patients. With frequent interruptions this is extremely difficult and if the nurse is called away from the drug cupboard or trolley has to lock up each time and then return and remember and resume her previous task.

    Many patients have their own GP and drugs may be delivered from different pharmacies. Prescriptions often require changing as a resident's condition changes or require repeat prescriptions. This may require phone calls to the practice and/or random visits to the home from the GP and further phone calls between deliveries to the pharmacy all of which take time.
    Many different pharmacies may be involved in delivering drugs to the same home and with the growing manufacture of generics there are a corresponding number of different packets of medication on the shelves of the drug cupboard which the nurse needs to be able to recognise rapidly. There are many different methods for preparing all the different doses of medications for a drug round and administration to patients. All of these also require considerable time and concentration to avoid errors.

    Errors can therefore be made at all these different levels as well as at the bedside or when giving the medication to a large number of patients/residents wherever they happen to be at the time. In homes patients may be in various locations and have to be found at the appropriate time of administration. Searching for them may also take some time in larger homes and grounds. Some may not be able to answer their own name and on occasions may be confused with another patient. It can also happen if a name is called another patient answers instead. Nurses may not know all the patients if there are new admissions of if s/he has just returned from leave. The round may take considerably longer than planned with patients requiring explanations, asking questions, serving a drink for them to swallow pills and helping those who need assistance in taking their medication. Furthermore nurses who prepared the drug round earlier in the day or the previous evening may not be the same as the one carrying out the drug round due to shift changes or different duties, etc. so all medication needs carefully checking at the point of administration.

    Administering medication several times a day and sometimes outside routine drug rounds is a complex and time consuming task where errors can occur at all levels and all the above mentioned factors, plus many others, such how they are prescribed and recorded as well as strict time constraints, have to be taken into consideration when planning and preparing and administering a drug round which rarely seem to be allowed to take place without MULTI- multitasking and constant interruptions at the same time!

    I would ask readers to reflect on the simplest of tasks they may carry out in a day and how long it takes to get back to when interrupted and to remember the exact point one had reached before the interruption (the subject of some empirical psychological studies). Apply this to the complexity and exacting task of drug administration it might be better understood that nurses need the time to carry out this task uninterrupted and why the tabards might be one of many good ideas to achieve this.

    Current methods of the administration of medicines in care homes, as well as in hospitals, need thorough examination of each of the different factors involved by all health care professionals involved in the chain i.e. nurses, health care assistants, doctors and pharmacists, the dispensing pharmacists, patients and home managers in order to simplify the methods of providing efficient and safer drug delivery.

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  • perhaps we could try out the red tabards that failed in hospitals - red rag to the bull, so to speak!

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  • Shift times and patterns need looking at in many nursing homes as 12/14 hour shifts are still run with single nurses-stress!!!!

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  • I worked in a nursing home where red tabards were in use. I didn't always wear one, due to the heat in the home and this was treated as breach of policy on my part.

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  • Anonymous | 3-Feb-2012 10:00 am

    at least you would have been quickly located if you had collapsed under the heat!

    rules are made to be bent and broken but some people are totally policy obsessed. Policy before People! what was the punishment for not complying in this instant and remaining a cool and more focused nurse on the drug round?

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  • To anon 3 Feb 11.59
    Everyone was so busy in their own work that they probably wouldn't have noticed I was missing until the next drug round!

    The management used the incident as part of a list of complaints against me, which I presume was going to lead to dismissal but I pre-emptied this by leaving.

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  • Anonymous | 4-Feb-2012 1:10 pm

    well in that case you deserve to be hung, drawn and quartered by the NMC, but I hope they saw sense and spared a nurse who uses her own initiative and common sense instead of following policies blindly.

    How short sighted of the home to put policies before the well being of their staff and probably lost a good nurse, to the detriment of their residents, as a result.

    I hope you find a better job where the employers support their staff as autonomous practitioners and allows them to use their own discretion and initiative.

    Good Luck.

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  • What use is a red tabard in a nursing home when a single nurse is on a 13hour shift with the drug trolley for the 3rd time that day. Its obvious there is a drug round in progress!! A red tabard is saying "do Not Disturb" but what happens when you have 25 patients 12 who are complex needs, a by passing catheter, problems with a peg feed, a relative who wants to discuss her parent's care and a new admission....its you and 2 carers!! What exactly are the NMC RCN and CQC doing????

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  • You know if I wasnt a Nurse workin in care homes I would think that the above was as it was dated,,, an April fool. Sadly it is not.
    We wear these tabards with due diligence saying do not disturb. How many of us have had people come up to us and say, " I know you are not to be disturbed but....". Yep probably almost all care home nurses.
    I work as the only nurse in home with 40 and sometimes in excess of 50 residents and am the only Nurse at times. And this is deemed as ok!
    There really is little wonder that care standards can slip. As the nurse you are the accountale one. How on earth can you check on everything that is happening when you spend almost your entire shift doing the meds. If truth be told it would be very nice if all residents in care homes had their meds reveiwed a bit more often. This alone would be beneficial to the residents and save us Nurses having to administer so many meds. This isnt being lay, there must be so many residents who are religiously taking meds which they simply do not need.

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