Medication administration in aged care facilities: A mixed-methods systematic review.
Stephanie Garratt, Alison Dowling, Elizabeth Manias
PMID 38973246WHAT IT FOUND
Pharmacist-led education for staff reduced medication administration errors.
However, practices like crushing tablets without asking residents or hiding medication in food were common and linked to harm. Staff time pressure and interruptions drove these errors and omissions.
Key findings
01Pharmacist-led education interventions significantly reduced medication administration errors.
02Dose form modification, such as crushing tablets or opening capsules, was common and often done without resident knowledge or staff expertise, leading to potential harm.
03Medication omissions were frequently classified as errors, even when they resulted from clinical decision-making or resident refusal, which discouraged accurate reporting.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Only English-language, peer-reviewed studies were included, potentially missing relevant non-English or grey literature. Medication error rates were reported inconsistently across studies, making direct comparison difficult. There was a lack of randomized controlled trials focusing on medication administration, limiting the strength of evidence for interventions. The perspectives of residents and families were under-represented in the included studies.
Declared interests
None to disclose.
The easy way to misread this
Do not assume that all medication omissions are errors. A significant proportion of omissions result from clinical decisions or resident refusal. Classifying these as errors can lead to under-reporting and may not reflect actual safety issues.