- The risks associated with problems swallowing tablets include the medication not being taken at all, medication being kept in the person’s mouth, unauthorised crushing of tablets and covert administration without the correct legal authority to do so.
- Liquid medicines can be used if an individual has difficulties with swallowing, but this carries a risk that errors may be made when measuring the medicine.
- Risks relating to creams include the incorrect dosage being administered because the cream has not been applied correctly, out-of-date creams being used, and flammable emollient creams, which present the most significant risk.
- The risks associated with medication must be assessed and mitigation measures put in place.
Medication is available in many different formats, the most common of which is tablets. Manufacturers of medicines choose the format for a number of reasons. These include: efficacy; effectiveness (efficacy is the performance of the medicine under ideal and controlled circumstances; effectiveness is its performance under ‘real-world’ conditions); cost of manufacture; adverse effects; and consumer demand.
Each form of medication also comes with risks, and care providers should try to manage these risks as part of providing ‘safe’ care. This article looks at some of the common types of medication, the associated risks and how these risks can be managed effectively. The emphasis is very much on real-world situations encountered in care homes and home care rather than on the ideal world of clinical environments.
Tablets are the most familiar form of medication, and this familiarity often breeds contempt. Many of us take tablets and have done so for many years. Some of us have a cavalier attitude towards medication, and fail to follow the manufacturer’s instructions regarding storage, time of administration and time between doses. We have got away with this mis-management, and this ingrained attitude can lead to poor practice when we administer medication to others in a professional capacity.
Some of the other risks involve swallowing problems. Some people have difficulties swallowing food, liquid and tablets. This may be for physical reasons, such as stroke, head injury, dementia, cancer and gastro-oesophageal reflux disease (GORD). Also, some people may have psychological dysphagia triggered by a bad experience when swallowing something such as a tablet. The risks associated with problems swallowing tablets include the medication not being taken at all, medication being kept in the person’s mouth, unauthorised crushing of tablets and covert administration without the correct legal authority to do so. These risks can be managed by the care provider undertaking a robust risk assessment and seeking the advice of the speech and language therapy team (SALT). This advice can then be conveyed to the prescriber with a request that the medication is prescribed in a format that makes it possible for the person to take the medication as prescribed.
Another risk is that tablets may be chewed or sucked. On occasion, care staff may notice that people, especially those who have a cognitive impairment such as dementia, may suck or chew tablets that are meant to be swallowed. This poses a risk that the medication may not be taken as prescribed. Again, this risk can be managed by being vigilant in noticing and recording incidents, having effective reporting systems in place, and risk assessment as described above.
If the medication is not managed effectively by the person and/or their care professional, the tablets may be dropped. This poses many risks, including contamination and lost medication. These risks are best managed by providing the person with appropriate equipment and/or support by trained care professionals.
Liquids may seem to be a convenient alternative to tablets, and it is true that liquids are often used to overcome issues with swallowing tablets. Liquids are not without their risks though, and the most common of these is measuring errors. There are many causes of measuring errors, including calculation errors, errors in reading the measurements on the pot, poor eyesight, or not all of the dose being taken, with some left in the pot. These risks can be managed by appropriate systems and effective training for care staff in the techniques required to administer liquid medication. Such training should include how to measure liquid using a pot or syringe.
Many people do not regard creams as medication. Evidence of this is the many cases of creams being stored in people’s bedrooms in care homes or next to radiators in people’s homes. Some other risks include the incorrect dosage being administered due to the cream not being applied correctly, out-of-date creams being used, and flammable emollient creams, which are the most significant risk. NICE provides guidance (NG67 and SC1) on the safe storage of medicines, including creams.
In respect of flammable emollient creams, the main risk is the likelihood of fabric that has been in contact with emollient products catching fire through an individual smoking or being near a naked flame. Fabrics that have come into contact with an emollient can be highly flammable, even after washing. The risk is greater when emollients are applied in large quantities or to large areas of the body. The Commission on Human Medicines (CHM) recommends that users should not smoke or go near naked flames, as fabric (such as clothing, bedding and dressings) that has been in repeated contact with these products burns more easily and can be a serious fire hazard. Washing clothing and bedding may reduce the build-up of products but does not totally remove it. Care providers should risk-assess individual circumstances and build their recommendations into risk management and care plans.
Better to be safe than sorry
The above are just some of the many risks associated with the administration of different types of medication: it is by no means an exhaustive list. Care providers are required under social care legislation and also under the Health and Safety at Work Act 1974 to take reasonable steps to ensure the safety of all those in the workplace. This includes staff and those who use the care service. The risks associated with medication must be assessed and risk mitigation measures implemented. Unless care providers take these simple steps, the service provision will not be regarded as safe. This then places the users of the service at risk of harm and may constitute a safeguarding matter.
- Managing medicines in care homes, NICE, March 2014: https://www.nice.org.uk/guidance/sc1
- Managing medicines for adults receiving social care in the community, NICE, March 2017: https://www.nice.org.uk/guidance/ng67
- Emollient cream build-up in fabric can lead to fire deaths, Gov.uk, December 2018: https://www.gov.uk/government/news/emollient-cream-build-up-in-fabric-can-lead-to-fire-deaths
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