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Liquid medicines main source of care home drug errors

By Christian Duffin

GPs working in care homes are more than four times likely to prescribe the wrong dose of medicine when it is in liquid form compared to when prescribing in capsule or pill form , research indicates.

The authors called for training for GPs who look after care home residents in the safe administration of different drug formulations.

Their research, published online in BMJ Quality and Safety, involved 233 residents randomly selected from 55 UK nursing and residential homes, providing a representative sample of different sizes, ownership, and type of care offered.

Administration errors were identified by pharmacists observing two drug rounds, and errors were classified and analysed by formulation and medicine delivery system.

The results showed that mistakes were 4.31 times as likely to be made with a liquid medicine as they were with a tablet or capsule given from a dispenser.

Compared with drugs given from a monitored dosing system, the likelihood of a mistake was 19 times higher when using a cream, injection or eye drop, and more than 33 times as likely when an inhaler was used.

Although the error rate was lower, mistakes were also made with tablets and capsules. The rate was twice as high for tablets and capsules provided in the manufacturer's original packing as it was for pills provided in a dispenser.

Lead researcher Dr David Alldred, a lecturer in pharmacy at the University of Leeds, concluded: ‘Inhalers have higher rates of administration errors than tablets and capsules, as they are complex devices requiring a number of steps to be correctly undertaken in the right sequence for successful administration.

'The main reasons why inhalers were administered erroneously in this study included not shaking the device, the resident not holding their breath – usually with visible powder escaping the mouth – and the wrong number of inhalations being administered.'

BMJ Quality and Safety 2011, online 7 February

The rate of errors was low when prescribing capsules, but errors still occurred

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