Dr David Alldred

Lecturer in Pharmacy
Academic Unit of Medicines Management
University of Leeds
d.p.alldred@leeds.ac.uk
Background
Patient safety initiatives of early 2000’s supplemented
by DH policy research initiative:
Patient Safety Research Portfolio at:
http://www.pcpoh.bham.ac.uk/publichealth/psrp
 Commissioned research on medication errors in care
homes.
 Care Homes’ Use of Medicines Study
•Prof Nick Barber (University of London)
•Prof Theo Raynor (University of Leeds)
•Prof Peter Buckle (University of Surrey)

www.pharmacy.ac.uk
Care homes’ use of medicines
study (CHUMS)
Aims
1. To identify the frequency and causes of medication
errors (prescribing, monitoring, dispensing,
administration)

2. To determine the potential harm

3. To suggest solutions

(Alldred et al 2009; Barber et al 2009)

Methods
256 randomly selected residents from 55 homes in W
Yorks, Cambs and London (38 mixed care)

Visited homes:
observed staff/records
observed medicines
observed administrations (2 drug rounds/resident)
interviewed care home staff.
Results
Mean age 85, on mean of 8 meds

7 out of 10 residents were exposed to at least one medication

error (mean of 1.9 errors/resident)

 Prevalence of prescribing errors 8.3% of medicines (39% of

residents)
 Monitoring errors 14.7% of medicines (18% of residents)
 Dispensing errors 9.8% of medicines (37% of residents)
 Administration errors 8.4% (22% of residents)
Administration errors
Prevalence of 8.4% (1 in 12)

Half were omissions, one-fifth wrong dose

Residential > Nursing? (adjusted OR 1.77 95% CI 0.96 to

3.25)
Types of administration errors
 Omission  Drug incorrect
 Allergy error  Formulation error
 Extra dose(s)  Route error
 Wrong dose  Deteriorated drug
 Unprescribed drug  Timing error
 Omission: Fluoxetine 20mg capsules were prescribed
“one daily” for depression and not administered for 6
days as drug not in stock.
 Wrong dose: Casodex® (bicalutamide) 150mg tablets
“one daily” were prescribed by the hospital for prostate
cancer; the prescription was continued by the GP
generically as bicalutamide and administered
simultaneously.
 Wrong dose: Glyceryl trinitrate patch prescribed
generically “5mg/24 hours take HALF daily” for
ischaemic heart disease. A patch was cut in half and
applied to the resident’s chest despite the fact that the
contents were leaking out.
Formulation and dispensing systems
 Compared different formulations to see if any
difference in error rates
 Monitored dosage systems versus manufacturers’
packaging

(Alldred et al 2011)
Formulation and dispensing systems
When compared to
tablets/capsules in MDS,
error rates were:

 Liquids – 4 times higher

 Omissions
 Not shaking bottle
 Inaccurate
measurement

(Alldred et al 2011)
 Formulation and dispensing systems
When compared to
tablets/capsules in MDS, error
rates were:

 Topical/transdermal/injections
– 19 times higher
 Omissions
 Wrong doses
 Expired

(Alldred et al 2011)
Formulation and dispensing systems
When compared to
tablets/capsules in MDS,
error rates were:

 Inhalers – 30 times higher

 Not shaking device
 Resident not holding
breath
 Spacer not used
 Wrong number of puffs

(Alldred et al 2011)
Formulation and dispensing systems
When compared to
tablets/capsules in MDS,
error rates were:

 Tablet/capsules not in
MDS – twice as high

(Alldred et al 2011)
Drug sensitivities
 Record review of 121 residents in 31 homes
 31 (26%) had ≥1 documented sensitivity
 48 sensitivities in total
 Number of sensitivities recorded by:
GP 35 (73%)
Care home records 29 (60%)
Medicines administration record 3 (6%)

 Only 2 sensitivities documented on all three records

(Alldred et al 2010)
Recording of drug sensitivities
Causes of errors (CHUMS)
 Human error theory
 Systems approach
 59 interviews with staff who made
errors
 Multiple causes
Accident Causation Model

ORGANIS- CONTRIBUTORY
FACTORS CARE MAN- DEFENCES/
ATIONAL & AGEMENT BARRIERS
CORPORATE INFLUENCING PROBLEMS
CULTURE PRACTICE
Work/
Environment Unsafe Acts
Factors
Team Factors
Management
Decisions Errors
Individual
and
Organisational
(staff) Factors Incident
Processes Task Factors

Patient Factors Violations

LATENT ERROR & ACTIVE

FAILURES VIOLATION FAILURES
PRODUCING
CONDITIONS
Causes of errors (CHUMS)
 Lack of patient awareness of medicines
 Physical problems e.g. dysphagia, arthritis
 Dispensing and ordering systems
 Lack of protocols
 Lack of knowledge and training
 Tired, unwell, stressed etc.
 Verbal rather than written culture
Causes of errors (CHUMS)
 Time pressure
 Staff turnover
 Drug round interruptions (up to 12 per hour)
 Poor communication with pharmacy and GP
 Lack of support from other healthcare professionals
 Inaccurate medicines administration records
 Physical environment –unpleasant smells, poorly lit,
noisy, shortage of space
Solutions
 Improve/increase education and training
 Drug round breaks
 Redesign the drug trolley
 Reduce number of medicines/doses
 Prescribe medicines more evenly over the day
 Improve communication with, and support from,
other healthcare professionals
 Adequate policies
 Technology e.g. barcoding, ordering systems
Summary
 Prevalence of administration errors is high and needs
reducing
 Medicine-related and patient-related factors may
increase the risk of error
 Causes are multiple
 Solutions need to be developed to improve systems
 Technology has a role
References
Alldred et al 2011. The influence of formulation and medicine delivery system on
medication administration errors in care homes for older people. BMJ Qual Saf
DOI: 10.1136/bmjqs.2010.046318

Alldred et al 2010. The recording of drug sensitivities for older people living in
care homes. Br J Clin Pharmacol 69:553-557

Alldred DP et al 2009. Care home use of medicines study. Medication errors in

nursing and residential care homes – prevalence, consequences, causes and
solutions. Report to the Patient Safety Research Portfolio. Available at
http://www.haps.bham.ac.uk/publichealth/psrp/PS025_Project_Summary.shtml

Barber ND et al 2009. The Care Homes’ Use of Medicines Study: prevalence,

causes and potential harm of medication errors in care homes for older people.
Qual Saf Health Care 18, pp.341-6. Available at
http://qshc.bmj.com/content/18/5/341.abstract

Dean B, Barber N. 2001. Validity and reliability of observational methods for

studying medication administration errors. Am J Health System Pharm 58:54–9.