20 June 2023
This clinical alert follows the preventable death of an aged care resident as a direct result of being administered medications that were not prescribed for them.
The coroner noted the resident’s death was due to a series of systemic errors and a wholesale lack of adequate checks and balances occurring when the service was transitioning from their original paper-based, handwritten medication charts to an electronic medication management (EMM) system.
- In this instance, the resident’s preventable death was linked to factors associated with the service’s implementation of a new electronic medication management (EMM) system. However, the circumstances of this death also underscore the importance for all residential aged care services of ensuring that they have ironclad protocols in place to prevent medication errors occurring at any time.
- When changing, updating, or transcribing a resident’s medication record/chart, it is strongly recommended that there is an effective process involving at least 2 people independently checking the medication records.
- GPs and prescribers should be aware of their overarching responsibility in signing either electronically generated or handwritten medication charts.
- It is important that residential aged care services conduct regular medication audits reporting to their medications advisory committee, and promptly address any issues detected.
- Where possible, ensure residents are informed about what medications they are taking. This can provide another layer of safety. Staff, residents, and involved family members should feel empowered to raise concerns or issues about residents’ medications.
- Ensure the 6 'rights' of administering medication are carried out every time: the right medication; the right dose; the right person; the right time; the right route; and the right documentation. Errors regarding these 6 fundamentals of medication management were frequently identified in analysis of medication related complaints to the Commission (PDF, 1.4 MB), indicating that more caution is required.
Nationally, residential aged care services are changing from paper-based medication charts to electronic systems of dispensing. EMM systems are perceived to be safer overall but transferring from one system to another is a high-risk process as this incident shows.
The residential aged care service employed a local pharmacy they had not used previously to take over the supply of medications to the service and to facilitate the changeover from a paper medication chart system to an EMM system.
The software company providing the EMM system incorrectly transcribed the medications from the resident’s paper chart to the electronic medications chart while assisting the local pharmacy (responsible for preparing the individualised medication packs) to implement the new system.
The general practitioner who signed off/approved the new electronic medication chart did not observe that incorrect dosages and additional medications for that resident were included on the new electronic medications chart.
The residential aged care service’s staff relied on the pre-packed medication and did not cross check the EMM chart against the old paper medication chart.
The error that occurred was a duplication of 2 residents’ profiles; a similarly named resident’s medication list, while being entered into the EMM system, was accidentally added to the chart of the resident who subsequently lost their life after being given that other person’s prescribed medication. The same or similar names are always a red flag when checking, prescribing, and administering medications.
Following this sad and preventable death, the residential aged care service conducted an internal review using the Department of Health’s Guiding Principles for Medication Management in Residential Aged Care Facilities aiming to identify gaps in their medication systems.
The service implemented the following reforms:
- Medication audits will be conducted at regular intervals and a further audit is conducted with pharmacy staff who attend the site every 4 months.
- Facility staff always check new medication packs against current drug charts.
- Staff will undergo regular and further training on medication administration.
Dr Melanie Wroth MB BS, FRACP
Chief Clinical Advisor