Accuracy of packaging of dose administration aids in regional aged care facilities in the Hunter area of New South Wales.
OBJECTIVE
To audit the accuracy of dose administration aid (DAA) packaging in regional aged care facilities (RACFs) within the boundaries of the Hunter Urban Division of General Practice.


METHODS
Each participating RACF audited one DAA for each resident receiving medication between May and August 2006. Registered nurses compared the contents with the medication chart prepared by the general practitioner and recorded any discrepancies as incidents.


METHODS
Number of medication incidents in the provision of DAAs.


RESULTS
297 incidents were detected from 6972 packs for 2480 residents (incident rate of 4.3% of packs and 12% of residents) from 42 participating RACFs. Reasons for incidents included medications missing from a pack (99 occasions), wrong medication dispensed (12), supply of the wrong strength (32), incorrect labelling (7), pharmacies supplying medication that had been ceased by the GP (37), incorrect dosage instructions (32), medications not delivered to the RACF (13).


CONCLUSIONS
The rate of incidents in DAA packaging in RACFs was high. The error types included incorrect packaging, correct packaging but the DAA was no longer required, and operational problems. Recommendations for improvement include: continuing audit and analysis by RACFs; streamlining of communications among GPs, pharmacists and RACF staff; using electronic methods to chart, order and dispense medications; use of generic names as much as possible; development of guidelines for the supply of medication in DAAs.
Carruthers
Annette
A
Hunter Urban Division of General Practice, Newcastle, NSW, Australia. acarruthers@hudgp.org.au
Naughton
Kialie
K
Mallarkey
Gordon
G
D000368:Aged; D004304:Dosage Forms; D004334:Drug Administration Schedule; D004349:Drug Packaging; D006707:Homes for the Aged; D006801:Humans; D008485:Medical Audit; D008508:Medication Errors / Q000706:statistics & numerical data*; D009517:New South Wales; D004364:Pharmaceutical Preparations / Q000008:administration & dosage*; D012041:Regional Medical Programs; D015203:Reproducibility of Results; D012307:Risk Factors
D004304:Dosage Forms; D004364:Pharmaceutical Preparations