Arnold Zermansky

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

No thank you: why elderly patients declined to participate in a research study.

Objectives: To compare the population consenting for a study of the effectiveness of a pharmacist‐run medication review clinic with the population not consenting for patients aged over 65 years old with respect to age, sex and number of repeat medicines. To explore the reasons why some patients declined to consent to the study.Methods: Letters were sent to 2,403 patients aged 65 and over and taking at least one repeat medicine from 4 general practices. If no reply was received to a second letter they were followed up by telephone. If they declined to consent they were asked for their reasons. Data for consenting and non‐consenting patients was collected on the stratification factors: age, sex and number of repeat medicines. Multiple logistic regression was used to assess the association of each factor with consent rates.Results: Consenting patients were dissimilar to non‐consenting patients. Patients were less likely to consent if they were older, OR (95% CI) = 0.54 (0.46,0.64), or female, OR (95% CI) = 0.74 (0.63,0.88). Patients were more likely to consent if on 5 or more repeat medicines: OR (95% CI) = 1.3 (1.1,1.5). Ten broad categories of reasons why patients did not wish to participate were identified from the patient interviews.Conclusions: Patients were less likely to give their consent if they were elderly, female and on fewer repeat medicines. A number of administrative and behavioural factors were identified which reduced the chances of informed consent being given. These factors need to be addressed to maximise numbers of consenting patients in medication review studies.

Is medication review by primary-care pharmacists for older people cost effective?: a narrative review of the literature, focusing on costs and benefits.

AbstractThe nature, definition and history of medication review of long-term conditions and treatment is discussed. A literature search for studies of medication review of older people in primary care by pharmacists yielded 16 reports of studies in English, and only ten of these were randomized controlled trials. Extracting meaningful conclusions from the data was problematic because of variations in the nature of the review described, the populations studied, the outcome data measured and the evaluation criteria used. There is a dearth of economic measurement and often inadequate descriptions of the interventions performed. Those interventions that were described in detail varied in the skills, training and approach of the pharmacists. Therefore, there was no possibility of aggregating results of studies, and the review conclusions are based on trends and impression rather than meta-analysis.There was no suggestion in any reports that patients were harmed by the interventions, and some consistency in suggesting that falls and hospital admissions might be reduced with modest cost savings, at least in terms of drug costs. No studies reported a benefit in terms of mortality, mental capacity or activities of daily living. The authors conclude that clinical medication review is probably of value and may be cost effective, but propose a large-scale, longterm, multicentre, collaborative clinical trial with carefully chosen (and clearly described) interventions and outcome measures to confirm this.

Development of a method for clinical medication review by a pharmacist in general practice

Medication review of patients on long-term treatment in general practice in the UK has been reported to be inadequate. Proposals followed suggesting that pharmacists could use their expertise to lead such a medication review in conjunction with the general practitioner. This paper describes the concept of clinical medication review by a pharmacist based in general practice. We describe the development of a method for a structured and systematic process for undertaking such a review in clinics conducted by a pharmacist. The method was developed for a nationally funded study in the UK. We provide a definition of clinical medication review and suggests a structure for the process through data gathering, evaluation and implementation.

Long-term prescribing of antidepressants in the older population: a qualitative study.

BACKGROUND High rates of long-term antidepressant prescribing have been identified in the older population. AIMS To explore the attitudes of older patients and their GPs to taking long-term antidepressant therapy, and their accounts of the influences on long-term antidepressant use. DESIGN OF STUDY Qualitative study using in-depth semi-structured interviews. SETTING One primary care trust in North Bradford. METHOD Thirty-six patients aged > or =75 years and 10 GPs were interviewed. Patients were sampled to ensure diversity in age, sex, antidepressant type, and home circumstances. RESULTS Participants perceived significant benefits and expressed little apprehension about taking long-term antidepressants, despite being aware of the psychological and social factors involved in onset and persistence of depression. Barriers to discontinuation were identified following four themes: pessimism about the course and curability of depression; negative expectations and experiences of ageing; medicine discontinuation perceived by patients as a threat to stability; and passive (therapeutic momentum) and active (therapeutic maintenance) decisions to accept the continuing need for medication. CONCLUSION There is concern at a public health level about high rates of long-term antidepressant prescribing, but no evidence was found of a drive for change either from the patients or the doctors interviewed. Any apprehension was more than balanced by attitudes and behaviours supporting continuation. These findings will need to be incorporated into the planning of interventions aimed at reducing long-term antidepressant prescribing in older people.

Clinical medication review by a pharmacist of elderly people living in care homes: pharmacist interventions

Objectives To describe the rate and nature of pharmacist interventions following clinical medication review of elderly people living in care homes.

Clinical medication review by a pharmacist of elderly patients on repeat medications in general practice — pharmacist interventions and review outcomes

Objectives — To describe the nature and rate of interventions made by a pharmacist conducting clinical medication reviews in general practice.

Development and validation of criteria to identify medication-monitoring errors in care home residents

Aim The identification of medication‐monitoring errors requires a validated definition. This paper describes the development and validation of a definition which includes criteria for specific medicines to determine whether a medication‐monitoring error has occurred in the care home setting.

The recording of drug sensitivities for older people living in care homes

AIMS The aims of this study were to determine the recording of drug sensitivities of elderly care home residents, to describe the nature of sensitivities and to identify and describe discrepancies in the documentation of drug sensitivity status in general practices, pharmacies and care homes. METHODS A random sample of residents within a purposive sample of care homes (nursing and residential) was selected. A clinical pharmacist inspected the GP medical record, the medicines administration record, and the care home record for each resident to identify drug sensitivities and discrepancies between records and to describe the nature of the recorded sensitivities. RESULTS The records of 121 residents in 31 care homes were studied. Thirty-one (26%) residents had at least one documented drug sensitivity in one of the sources inspected, with 48 sensitivities in total recorded. There was no description of the nature of the sensitivities recorded in 39/48 (81%) cases. The number of sensitivities recorded on the medicines administration record, care home record and the GP record were 3 (6%), 29 (60%) and 35 (73%), respectively. Only two sensitivities were simultaneously recorded on all three records. CONCLUSIONS It was of concern that over 90% of drug sensitivities were not recorded on the medicines administration record which is the final checking document when administering medication. The reason for this was that the dispensing pharmacy was responsible for generating the medicines administration record; however, drug sensitivity status is seldom shared between the GP and the dispensing pharmacy. Printing sensitivities on prescriptions would help to resolve this.

Accountable… but to whom?

In proposing accountability as the missing attribute of NHS management, you stop short of exploring its inherent conflict.1 For 65 years doctors and nurses have wrestled with having two masters, the patient (as ever) and the Service. The NHS has relied upon them juggling this tension within an overarching doctrine of patient priority. The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) have been the ultimate arbiters of this, explicitly describing professional and unprofessional conduct. Paradoxically, doctors derive comfort from GMC disciplinary activity when it reinforces patient primacy, sometimes iconoclastically, as a few senior doctors have found to their cost.