- The problem of medication management persists, according to CQC's latest State of Care report.
- 10% of services are rated as inadequate for the 'safe' key line of enquiry (KLOE).
- All medication must be stored securely and safely.
- Medication must be labelled with the 'open' date and 'use by' date.
- HACCP (hazard analysis and critical control points) systems will prevent medication administration errors.
- Investigate the root cause of every medication error.
In October 2013, we featured an article on medication administration in social care. In this article, we refer to the Care Quality Commission (CQC) report The State of Health Care and Adult Social Care in England 2012/13 and, in particular, the non-compliance issues that led to medication errors that the CQC identified. These were:
- lack of information given either to those taking the medicines or those caring for them
- more complex drug treatments
- significant growth in co-morbidity.
The article then looked at ways in which care providers could combat medication errors.
In October 2015, the CQC published its report The State of Health Care and Adult Social Care in England 2014/15. This is the first such report on the findings of inspections under the new Health and Social Care Act 2008 Regulations 2014 (the fundamental standards).
The issue of medication is covered in the 'safe' key line of enquiry (KLOE), and CQC reports that 10% of adult social care services were rated as inadequate for this KLOE. Similarly, a lower proportion of services were rated good or outstanding for the 'safe' KLOE. Sadly, this confirmed the findings of the 2012/13 and 2013/14 State of Care reports. So, medication management remains a concern for both the adult social care sector and CQC. Specific concerns about medication reported by CQC include:
- storage of medication
- out-of-date medication
- administration errors.
This article looks at some ways that care providers can prevent non-compliance occurring in their service. It considers how they can take positive action to prevent this leading to a rating of 'requires improvement' or 'inadequate' for the 'safe' KLOE.
Medication should be stored securely in line with relevant legislation. For example, controlled drugs must be stored in a controlled drugs cabinet and in accordance with the manufacturer's instructions. The most common areas of non-compliance include the following.
Often the storage area is inadequate, for example a cupboard is used that can be accessed because of an insecure lock. The storage area may be left unlocked when unattended or the keys may be left in the lock or on top of the medication trolley.
Care providers also need to consider the temperature at which medication must be stored. This will usually be either below 25⁰C or, for medication stored in a fridge, between 1⁰C and 5⁰C. Records must be kept of the storage temperatures and action taken when the storage temperature nears the maximum permitted by the manufacturer's instructions.
Care providers must consider whether storage conditions are appropriate. For example, creams are often stored in service users' bathrooms for ease of use, rather than in the required cool and dry place.
Systems and practice
Inadequate medication storage systems and practice can lead to an increased risk to the service user, which can mean the service is not regarded as safe.
Medication should only be administered in accordance with the prescriber's and the manufacturer's instructions. These will be on the label affixed to the medication and the patient information leaflet respectively. Use by dates must be adhered to in order to ensure safe administration of medication. The problem of out-of-date medication arises from: poor stock control; not labelling liquids, tubes and tubs with the open date and the use by date; poor control of PRN (as required medication); and over-ordering of repeat medication. All of these errors are preventable. A robust ordering, administration and audit system will ensure that this aspect of the 'safe' KLOE is complied with.
Statistically, it is likely that some medication administration errors will occur. A care home that supports 40 service users may well administer 10 different medicines per person per day. This is 400 medication administration events per day, or 146,000 events each year. Yet, all administration errors are the result of human error and all are avoidable. Common reasons for medication administration errors include:
- more than one person administering the medicine – i.e. one person dispensing medication into a pot and another person taking it to the service user; or even worse, service users taking it to the person taking the medicine
- lack of concentration and/or rushing (prevalent in home care settings)
- interruptions by service users, families and other staff
- hand-written or altered medication administration record (MAR) charts
- not reading the MAR chart or checking the label before giving medicine
- not knowing what the medication is for, how it works and how it is to be administered
- not knowing the day/date/time
- poor eyesight and failing to wear spectacles
- medication left for the service user to take.
All of the above are preventable by implementing a robust medication procedure backed up with training and competency assessments. Care providers should keep records of all medication administration errors and investigate every single error to identify the root cause. Analysis of the cause is designed to identify which part of the system failed, resulting in the error. Once the provider has identified the cause (and if records of errors are kept), they will be able to identify trends and take action to make the system more robust.
Tools such as HACCP (hazard analysis and critical control points), as used in catering, can be used to make medication administration systems safer. Care providers seeking to demonstrate that their service is good or even outstanding in this area may consider comparing their medication error analysis with those of other providers and collaborating to learn from the mis-takes of others.
Medication management is a key component of a safe service, but since 2012 CQC has been highlighting concerns over this aspect of care. In the interim, service users have died as a result of poor medication management and staff and registered managers have been prosecuted for manslaughter by gross negligence. Robust systems operated by well-trained and competent staff whose practice is supervised and audited will result in safer care provision and hence better ratings for service providers.
- The State of Health Care and Adult Social Care in England 2014/15, CQC, October 2015; http://bit.ly/StateCare201415
- 'Medication in care services: preventing errors', Quality & Compliance Magazine, October 2013; http://bit.ly/QandCMedication
Use the following items in the Toolkit to help you put the ideas in this article into practice:
- Policy – Crushing or altering medication (all providers)
- Form – GP or pharmacist approval/advice for crushing or altering medication (all providers)
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