Date: 29 November 2007
Title: Accuracy of packaging of dose administration aids in regional aged care facilities in the Hunter area of New South Wales

Annette Carruthers, Kialie Naughton and Gordon Mallarkey
Med J Aust 2008; 188 (5): 280-282.

Med J Aust 2008; 188 (5): 280-282.
Received 3 Sep 2007, accepted 29 Nov 2007



Objective:  To audit the accuracy of dose administration aid (DAA) packaging in regional aged care facilities (RACFs) within the boundaries of the Hunter Urban Division of General Practice.

Design, participants and setting:  Each participating RACF audited one DAA for each resident receiving medication between May and August 2006. Registered nurses compared the contents with the medication chart prepared by the general practitioner and recorded any discrepancies as incidents.

Main outcome measures:  Number of medication incidents in the provision of DAAs.

Results:  297 incidents were detected from 6972 packs for 2480 residents (incident rate of 4.3% of packs and 12% of residents) from 42 participating RACFs. Reasons for incidents included medications missing from a pack (99 occasions), wrong medication dispensed (12), supply of the wrong strength (32), incorrect labelling (7), pharmacies supplying medication that had been ceased by the GP (37), incorrect dosage instructions (32), medications not delivered to the RACF (13).

Conclusion:  The rate of incidents in DAA packaging in RACFs was high. The error types included incorrect packaging, correct packaging but the DAA was no longer required, and operational problems. Recommendations for improvement include: continuing audit and analysis by RACFs; streamlining of communications among GPs, pharmacists and RACF staff; using electronic methods to chart, order and dispense medications; use of generic names as much as possible; development of guidelines for the supply of medication in DAAs.