Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

BMC Geriatrics

Johanna Westbrook¹  Andrew Georgiou¹  Amina Tariq¹ 

[1] Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia

关键词: Information exchange;    Long term care;    Residential aged care facilities;    Incident reporting;    Medication management;   

Others  :  1090221
DOI  :  10.1186/1471-2318-12-67

 received in 2012-03-05, accepted in 2012-09-04,  发布年份 2012

【 摘 要 】

Background

Medication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs.

Methods

The study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach.

Results

The findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs.

Conclusions

This study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.

【 授权许可】

   
2012 Tariq et al.; licensee BioMed Central Ltd.

【 图 表 】

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