Home' Australian Pharmacist : Australian Pharmacist April 2012 Contents Australian Pharmacist April 2012 I © Pharmaceutical Society of Australia Ltd.
audits of medicine charts and a facility for
archiving older versions.
The medicine class most frequently
involved in errors were medicines
affecting the nervous system, which
may, in part be due to the frequent use
of analgesics, sedatives and behaviour-
modifying medicines in ACFs.20
Unauthorised alteration of dosage form/
drug packaging was a common type of
error, indicating that the significance
of making this type of change may be
underestimated by pharmacy staff.
Pharmaceutical manufacturers who were
contacted commented that no stability
data was available for tablets removed
from original foil seals for any of the
medicines involved in this type of error,
and as such, their recommendations
were that these medicines should not be
packed into DAAs. Whilst it may be that
inappropriate alteration of dosage forms
is unavoidable (e.g. for patients unable
to swallow solid oral dosage forms), this
particular study was concerned more
with drug stability and degradation of
altered dosage forms packed into DAAs.
Alteration of dosage forms by nursing
staff upon their removal from the DAA
was not identified and recorded.
Study limitations are acknowledged.
Both the participating pharmacy and
ACFs were aware of the study, which
may have led to increased vigilance of
pharmacy staff responsible for both
packing and checking DAAs. While the
sample size of ACF residents was small
(n=91), it was appropriate for a pilot study
whose aim was to gather preliminary
data to determine the need for future
research. Finally, as there was a single
participating pharmacy, it may be difficult
to extrapolate the study findings to other
pharmacies that may have different
packing and checking procedures.
The error rate observed was considerably
higher than rates reported previously
in similar studies in the residential aged
care setting.9,11–12 Further research is
required to validate these findings and
form the basis of guidelines/standards
outlining correct procedures for the
training of packing staff, particularly
technicians, and the packing of DAAs
in order to minimise errors, particularly
those systematic in nature and related to
the inappropriate alteration of dosage
forms. Published guidelines may form
a starting point for this.14 However,
possible improvements may outline the
specific obligations, responsibilities and
duties of all parties involved, and the
procedure and time intervals required
for regular, individual patient audits.
Furthermore, possible causes for error
were not considered within the scope of
this pilot study and may form the subject
of further investigation.
1. Elliott RA. Problems with Medication Use in the Elderly: An
Australian Perspective. J Pharm Pract Res 2006;36(1):58–66 .
2. Roughead EE, Semple SJ, Gilbert AL. Quality use of
medicines in aged-care facilities in Australia. Drugs Aging
3. Cheek J, Gilbert A, Ballantyne A, Penhall R. Factors influencing
the implementation of quality use of medicines in residential
aged care. Drugs Aging 2004;21(12):813–24.
4. Simonson W, Feinberg JL. Medication-related problems in
the elderly: defining the issues and identifying solutions.
Drugs Aging 2005;22(7):559–69 .
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risk factor for adverse drug reactions in geriatric nursing
home residents. Am J Geriatr Pharmacother 2006;4(1):36–41 .
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Regions of Australia, 2008. Canberra: Australian Bureau of
Statistics; 2009. Available from: www.abs.gov.au/ausstats/
08&num=&view=>. Accessed 19 Nov 2009.
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to 2050: future challenges. Australian Capital Territory:
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administration aids (DAAs). Brisbane: School of Medicine,
University of Queensland; 2004.
10. Barber ND, Alldred DP, Raynor DK, Dickinson R, Garfield
S, Jesson B, et al. Care homes’ use of medicines study:
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errors in care homes for older people. Qual Saf Health Care
11. Carruthers A, Naughton K, Mallarkey G. Accuracy of
packaging of dose administration aids in regional aged care
facilities in the Hunter area of New South Wales. Med J Aust
12. Gerber A, Kohaupt I, Lauterbach KW, Buescher G, Stock
S, Lungen M. Quantification and classification of errors
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term care facilities in Germany. Am J Geriatr Pharmacother
13. Vowles E. Dose administration aids: evidence to inform
practice. Aust J Pharm. 2007;88(1050):62–5 .
14. Pharmaceutical Society of Australia. Guidelines and
Standards for Pharmacists: Dose Administration Aids Service.
Canberra: Pharmaceutical Society of Australia; 2007.
15. Australian Pharmaceutical Advisory Council. Guidelines for
medication management in residential aged care facilities.
3rd Edition. Canberra: Australian Pharmaceutical Advisory
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implementation of the APAC Guidelines for Medication
Management in Residential Aged Care Facilities. In:
Department of Human Services, editor: Department of
Human Services; 2006;1-89.
17. Hepler CD, Strand LM. Opportunities and responsibilities in
pharmaceutical care. Am J Hosp Pharm 1990;47(3):533–43.
18. World Health Organisation Collaborating Centre for Drug
Statistics Methodology. ATC/DDD Index 2009. Oslo: World
Health Organisation Collaborating Centre for Drug Statistics
Methodology; 2009. Available from: <http://www.whocc.no/
atcddd/> Accessed 02 Dec 2009.
19. New South Wales Health. Severity Assessment Code (SAC).
In: Department of Health, editor: New South Wales Health
Department for and on behalf of the Crown in right of the
State of New South Wales; 2005.
20. Snowdon J, Day S, Baker W. Audits of medication use in
Sydney nursing homes. Age Ageing, 2006;35(4):403–8 .
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