Home' Australian Ageing Agenda : AAA Jan-Feb 2017 Contents Call for improved
MEDICATION ERRORS in aged care are
common and their potential to cause harm is
high, yet the reported serious effects of errors
on residents are rare, according to Monash
However, medication errors resulting in serious outcomes including
permanent disability or death are probably underreported or undetected
because other reasons are plausible among this frail population and complex
medication environment, the researchers say.
The international study looked at the prevalence of medication errors
leading to hospitalisations and deaths through 11 studies published between
2000 and 2015.
It found medication errors were common and involved 16 per cent to
27 per cent of residents in studies examining all types of medication errors.
Errors occurred in 13 per cent to 31 per cent of residents in studies looking at
transfer-related medication errors and 75 per cent of residents were prescribed
at least one potentially inappropriate medication, according to the research.
The serious impacts of medication errors were reported in only 1 per
cent of medication errors, the research found.
However, senior researcher on the study, Monash University academic
physician in geriatric medicine Joseph Ibrahim says that result is likely due
The team expected to see a lot more serious complications from
subtle things such as late or slightly changed doses and combinations, or
forgotten tests, or other problems related to medications such as falls and
aspirations, he says.
“That wasn’t there, which made us think people only picked up on the
deaths if they were really obvious; that you couldn’t find another plausible
reason,” Ibrahim tells Australian Ageing Agenda.
He says medication management is ver y complicated so it is not
surprising there are a large number of errors, but there needs to be a better
way of measuring.
“You don’t get patted on the back if you report a medication error... we
need to be looking at improving our response to reporting,” Ibrahim says.
The findings are published in the Journal of the American Geriatrics Society.
Sedative impact on
A MONASH UNIVERSITY study involving six
Australian residential aged care facilities has
found short-acting benzodiazepines used on an
as needed basis are associated with lower night
time sleep quality and longer day-time napping
compared to long-acting regular benzodiazepines.
The study surveyed 383 participants to assess
their night-time sleep quality, day-time drowsiness
and day-time napping behaviour.
A quarter of the residents used a
benzodiazepine on a regular basis, one in five on
an as needed basis and most likely a short-acting
variety while 10 per cent used more than one
category of benzodiazepine.
Residents who used benzodiazepines had
a higher prevalence of diagnosed insomnia,
anxiety and depression plus higher prevalence of
agitation or aggression than those who did not.
The researchers found that residents regularly
using long-acting benzodiazepines had higher
night-time sleep quality than non-users while
residents using short-acting benzodiazepines
on an as needed basis only had longer daytime
napping times than non-users.
Specialist palliative services needed to reduce
unnecessary hospitalisation near end of life
ALMOST ONE in 11 residents who
died in their aged care facility were
transferred to hospital and returned
home in the week prior to their
death, according to a Victorian-
The researchers found limited
involvement in specialist palliative
care ser vices among this group and a
potential lack of knowledge and skills
in assessing residents and recognising
signs of nearing end of life.
The study published in
the International Journal of
Palliative Nursing looked at the
resident deaths of a large not-for-
profit provider with 13 facilities and
more than 800 beds, all of which
had access to local specialist palliative
care ser vices, across metropolitan
and regional Victoria from July
2014 to June 2015.
Of the 252 deaths in that year,
the vast majority occurred in the
facility (86 per cent).
But 9 per cent of these residents
were transferred to hospital and
returned home in the last week
of their life. Nearly one-third of
this group died within 24 hours of
returning home and more than half
died within two days.
Respirator y problems, general
deterioration and pain management
were among the top reasons
Lead researcher and Monash
University PhD candidate Jenny
Davis says there were a number
of the transfers that perhaps could
the things that
by the staff and
tells Australian Ageing Agenda.
The issue is recognising a resident
is declining and making decisions
about making them comfortable
and discussing their end of life care,
The findings show there are
opportunities to improve skills for
assessing residents before calling an
ambulance and providing access to
early referral or universal palliative
care ser vice, Davis says.
Professor Joseph Ibrahim
48 | JANUARY – FEBRUARY 2017
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