title: Medication incident reporting in residential aged care facilities: limitations and risks to residents' safety.
abstract: 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.
authors.affiliation: Centre for Health Systems and Safety Research, University of New South Wales, Kensington, Sydney, Australia. amina.tariq@unsw.edu.au
authors.forename: Amina
authors.initials: A
authors.lastname: Tariq
authors.forename: Andrew
authors.initials: A
authors.lastname: Georgiou
authors.forename: Johanna
authors.initials: J
authors.lastname: Westbrook
mesh_terms: D064420:Drug-Related Side Effects and Adverse Reactions; D005500:Follow-Up Studies; D006707:Homes for the Aged / Q000592:standards*; D006801:Humans; D009517:New South Wales / Q000453:epidemiology; D061214:Patient Safety / Q000592:standards*; D012112:Residential Facilities / Q000379:methods / Q000592:standards*; D012189:Retrospective Studies; D012308:Risk Management / Q000379:methods / Q000592:standards*; D011795:Surveys and Questionnaires