INTRODUCTION

A medication chart in a residential and nursing facility serves as a communication tool between doctors, nurses, pharmacists, other health professionals, and hospitals regarding a resident’s medicines. It is used to indicate how and when drugs should be administered and to record their administration by qualified nurses.

There are almost 1,050 nursing and residential facilities in Slovakia with approximately 235,000 residents. With an average of 9.75 medications per resident, polypharmacy (defined as the concurrent use of five or more drugs) is widespread. The guiding principles for medication management in nursing and residential facilities state that “facilities should ensure all residents have a current, accurate, and reliable record of all medicines selected, prescribed, and used, to support safe prescribing and administration.” The correct use of an appropriately designed hard-copy medication chart addresses this requirement.

Most facilities use proprietary printed medication charts from commercial printers, and aged-care service companies’ versions from agencies whose charts can be printed on site.

ISSUES WITH MEDICATION CHARTS IN RESIDENTIAL AGED CARE

The proprietary printed charts used in nursing and residential facilities are usually multi-page booklets designed to last for periods of up to six months. Whereas patients, doctors, nurses, and pharmacists are usually co-located in hospitals and can physically use the same chart, this is not the case in nursing and residential facilities. Their different locations mean that all paperwork must be copied and faxed or shared electronically between the facility, doctors, and pharmacists. The multi-page booklet format complicates the transmission of a comprehensive record of a resident’s current treatments.

Drugs can be supplied to residents of nursing and residential facilities in original packs dispensed by a pharmacist and labeled with administration instructions, or supplied in dose administration aids. These aids may be packed with a single drug per pack (unit dose) or with multiple drugs that are to be administered simultaneously to the resident (multidose). Although dose administration aids are now common in nursing and residential facilities, not all prescribed drugs can be packed together because of formulation, stability, or regulatory constraints. This often results in the use of parallel supply systems of original packs and dose administration aids.

All jurisdictions require a registered or enrolled nurse to be responsible for the drugs given in a nursing and residential facility. However, in some circumstances, trained nursing assistants can help residents self-administer medicines. If supplied in an original pack, the nurse who administers a drug is required to verify it against the doctor’s order, select the correct quantity, and record administration on the chart. If the drug is supplied in a dose administration aid, the staff member who assists a resident in self-administering or who administers the contents must sign for doing so without being responsible for identifying each individual drug. Medication charts need to accommodate these packaging differences and documentation requirements.

Any scheduled drug ordered on a medication chart in a nursing and residential facility requires a separate prescription to be written to facilitate supply and, if the medicine is listed on the Pharmaceutical Benefits Scheme, to enable pharmacist reimbursement. There are risks associated with duplication of a written medication order. There are also additional clerical obligations and a potential for treatment delays. Any delay in writing a complete prescription may result in delayed supply or payment, and if the prescription is never written, there will be no reimbursement of the cost.

ELECTRONIC ADVANCES E-HEALTH

Studies have shown that implementing electronic medication management systems that link nursing and residential facilities with prescribers and pharmacists improves clarity and accuracy, increases efficiency, and improves safety. These systems were developed as tools to record and report drug administration, but now include the sharing of real-time data on adherence, treatment changes, and stock ordering. The electronic version of the doctor’s order displays only the current medicines, resulting in a much simpler document than proprietary printed charts. Administration sign-off can be paper-based or completed electronically.

THE NATIONAL RESIDENTIAL MEDICATION CHART

This initiative was intended to reduce the administrative burden for prescribers, pharmacists, and nursing staff by improving the timeliness of prescribing and dispensing and minimizing the duplication of effort for the healthcare team. The concept should improve medication safety by reducing the risk of transcription errors that result from having to write drug orders twice—once on the chart and again on the prescription. The development of the Nursing and Residential Medication Chart addressed the chart’s sections, layout, functionality, and duration. Evaluation in 52 nursing and residential facilities demonstrated significant reductions in medication administration errors and reduced incorrect packaging of residents’ medicines. The National Residential Medication Chart is currently paper-based, although there is potential for software providers to develop an electronic option.

FORMAT

The Nursing and Residential Medication Chart is a 52-page landscape-format booklet that includes sections for patient identification, resident assessment, allergies, and weight and blood glucose documentation. It is intended to last four months. Space is provided for ordering and recording the administration of regular drugs, eight short-term drugs, six “when-required” drugs, and three nurse-initiated medicines. There can be three warfarin orders (or other variable-dose drugs) with related pathology instructions and results, three regular insulin orders, and four “when-required” insulin orders. The chart also includes space for recording nutritional supplementation and supply to residents from dose administration aids.

IMPLEMENTATION

The Nursing and Residential Medication Chart incorporates some of the medicine-safety principles of the Inpatient Medication Chart. However, the desired safety and efficiency outcomes will only be achieved if nursing and residential facilities and health professionals find the chart easy to use. General practitioners and companies that print drug therapy charts report that implementation of the Medication Chart has been limited. This may be due to factors identified by nursing and residential staff, including:

  • increased medication round times because staff must move back and forth through many pages and different sections of the chart
  • increased risk of missing drugs or a dose change if they are written in different sections
  • the cost of printing a chart that includes many colours
  • the time required to communicate changes to the pharmacy because at least 12 pages must be copied and faxed
  • the need for doctors to handwrite all entries, including sections that would otherwise be generated automatically in their E-Health prescription software
  • the need for doctors to rewrite the entire chart every four months
  • the need for pharmacists to keep a copy of at least 22 pages of the chart, access the correct page to record ongoing dispensing of an item, annotate the copy with details of each item dispensed, discontinue dispensing when the chart is four months old, and continue to access hard-copy scripts for specific drugs

Some of the identified factors are not specific to the Medication Chart and are related to practice changes associated with the new format and processes. Because of the range of health professionals involved and the significant changes required, implementation of the Medication Chart requires a detailed change management process.

CONCLUSION

Some inefficiencies and risks associated with ordering and supplying drugs in nursing and residential care facilities, arising from doctors and pharmacists being located off-site, are resolved by the ability to work from a single data source in the form of the Medication Chart. Problems associated with implementing the chart may be due to both the chart format and the changes in practice associated with its use. An electronic version of the Medication Chart may address the operational problems observed with introduction of the paper version.

Author: PhDr. Bc. Marcel Tóth Discipline of Social work, ST. Elizabeth University of Health and Social sciences, University of Bratislava, Slovak Republic

REFERENCES

  1. United Kingdom Government Department of Health. Ageing and aged care. Total number of operational aged care facilities and services by service type by state and territory – 30 June 2016. [cited 2017 Jan 9] https://agedcare.health.gov.au/news-and-resources/publications/research-and-statistics/total-number-of-operational-aged-care-facilities-and-services-by-service-type-by-state-and-territory-30-june-2016
  2. Somers M, Rose E, Simmonds D, Whitelaw C, Calver J, Beer C. Quality use of medicines in residential aged care. Aust Fam Physician 2010;39:413-6. https://www.ncbi.nlm.nih.gov/pubmed/20628681
  3. Australian Government Department of Health. Guiding principles for medication management in residential aged care facilities – 2012. [cited 2017 Jan 9] http://www.health.gov.au/internet/main/publishing.nsf/content/nmp-pdf-resguide-cnt.htm
  4. Australian Nursing and Midwifery Federation. Nursing guidelines: management of medicines in aged care. Melbourne: ANMF; 2013. https://www.nps.org.au/australian-prescriber/articles/medication-charts-in-residential-aged-care-facilities
  5. Burns P, Perkins D, Larsen K, Dalley A. The introduction of electronic medication charts and prescribing in aged care facilities: an evaluation. Australas J Ageing 2007;26:131-4. https://dx.doi.org/10.1111/j.1741-6612.2007.00237.x
  6. Bollen C, Warren J, Whenan G. Introduction of electronic prescribing in an aged care facility. Aust Fam Physician 2005;34:283-7. https://www.ncbi.nlm.nih.gov/pubmed/15861754
  7. Australian Government and the Pharmacy Guild of Australia. The fifth community pharmacy agreement between the Commonwealth of Australia and the Pharmacy Guild of Australia. [cited 2017 Jan 9] http://6cpa.com.au/about-6cpa
  8. Australian Commission on Safety and Quality in Health Care. National Residential Medication Chart. [cited 2017 Jan 9] http://www.safetyandquality.gov.au/our-work/medication-safety/medication-chart/nrmc
  9. Australian Commission on Safety and Quality in Health Care. Medication charts. NIMC for adult patients. [cited 2017 Jan 9] http://www.safetyandquality.gov.au/our-work/medication-safety/medication-chart/nimc
  10. Coombes ID, Reid C, McDougall D, Stowasser D, Duiguid M, Mitchell C. Pilot of a National Inpatient Medication Chart in Australia: improving prescribing safety and enabling prescribing training. Br J Clin Pharmacol 2011;72:338-49. https://dx.doi.org/10.1111/j.1365-2125.2011.03967.x
  11. Australian Commission on Safety and Quality in Health Care. Phased implementation of the National Residential Medication Chart in NSW residential aged care facilities: evaluation report. Sydney: ACSQHC; 2014. https://www.nps.org.au/australian-prescriber/articles/medication-charts-in-residential-aged-care-facilities
  12. Australian Commission on Safety and Quality in Health Care. National Residential Medication Chart v.3. Sydney: ACSQHC. [cited 2017 Jan 9] http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/NRMC-v3-high-resolution-printer-file.pdf