INTRODUCTION

With the increasing population, the demand for health and social care and for the provision of high-quality care for older adults in Slovakia is also growing. These services should meet the needs of individuals who may have a range of acute and chronic conditions. The ability of hospital services to meet these demands is limited, and therefore social service facilities provide accommodation and health services to address this unmet need. Concerns regarding drug management in social service facilities have appeared in the lay press, and the literature demonstrates that this process is not optimal. The aim of the research was therefore to examine drug management in social service facilities with emphasis on the areas of prescription, administration and drug waste.

Prescribing practices should be carefully considered to reduce the drug burden, and efforts should be made to incorporate a multidisciplinary approach to care. For better and more efficient drug management, there is the Drug Monitoring System (MSDL). MSDL is a storage device for solid medicines designed to simplify drug administration to patients/clients. MSDL offers new possibilities for medication packaging for various social service facilities, for patients at home or in other healthcare facilities such as hospitals. MSDL is packaged by leading or qualified nurses directly in the facility or at home, in a simple manner. This system enables patients/clients to easily take medications in daily doses as prescribed by their attending physician. It is stated that MSDL has a number of benefits, including increased patient compliance with treatment regimens and minimization of medication dosage errors.

In our country, not only have financial pressures increased, but the recruitment of staff in the social services sector continues to be challenging. There is a significant shortage of nurses, caregivers and care workers who could contribute to better delivery of social services linked to health services in social service facilities. Studies suggest that nurses prefer working in primary or secondary healthcare rather than in the social services sector. This is partly due to improved access to resources and a multidisciplinary environment in such settings, which are inadequate in the social services sector. Another pressure on this industry is increased regulatory oversight (care standards, ÚDZS) as a result of several significant incidents in care facilities involving clients. This oversight is understandable, as clients of social service facilities often represent the most vulnerable individuals in society. But it is worth it. Together, these pressures may affect the provision of effective and quality care. One of the main nursing tasks in social service facilities is also the administration of medications prescribed by the attending physician for individual clients. Typically, in social service facilities clients are unable to manage their own medications, and therefore staff participate in managing, administering and distributing medications.

Evidence suggests that clients in social service facilities are particularly susceptible to drug-related harm, due to weak information provided about various drug allergies in prescribing and inappropriate administrative practices in facilities, although this area remains inadequately researched. As a result, this work addresses drug management in a sample of social service facilities focusing on drug prescribing, administration and waste.

Study objectives

The aim is to examine drug administration management in social service facilities providing accommodation, with emphasis on the areas of prescription, administration and drug waste. To achieve this objective, analysis of drug administration records and drug return records to pharmacies was used.

  1. The first objective of this study is to examine drug prescription to clients in social service facilities.

Sub-objectives are:

  1. Identify medications prescribed for clients living in social service facilities.
  2. Assess the prevalence of polypharmacy and excessive polypharmacy among social service recipients. Polypharmacy occurs in clients who take 5 or more medications daily.

  3. Assess the prevalence of potentially inappropriate medications (PIMs) prescribed for clients in social service facilities.

  4. The second objective of this study is to identify the types and prevalence of errors in drug management in social service facilities through analysis of Drug Records. The Drug Record serves as a document for health personnel to record medication administration to the client. It contains information about the client, physician, names of medications and the time of medication administration.

Sub-objectives are:

  1. Characterize types of errors such as forgotten signatures of nurses or caregivers indicating they administered medication to the client, unrecorded client drug allergies, dosage timing errors and similar issues that can be identified through Drug Records. The Drug Record serves the nurse in administering medications to the client without causing errors.
  2. Conduct analysis of Drug Records to quantify the identified errors.

  3. Identify the occurrence of errors associated with potentially inappropriate medications (PIMs). The Ministry of Health of the Slovak Republic categorizes medications in accordance with the needs of all age groups.

  4. The third objective of this study is to examine the types and quantities of medications returned to pharmacies in a sample of social service facilities.

Sub-objectives are:

  1. Quantify the value of wasted medications from records of medication returns to pharmacies.
  2. Quantify the value of excessively stocked medications in social service home facilities. Some facilities have large quantities of medications with poor tracking, e.g., of medication expiry dates, or errors occur when changing prescriptions for clients, etc.
  3. Examine the types of medications disposed of in this sample of social service facilities.

Research problem

The population of adults over 65 years of age (older adults) is growing worldwide. A major study in 2010 predicted that due to increased life expectancy in both developed and developing countries, the older adult population will continue to grow over the next four decades (Stegemann et al. 2010,) p. 116; this increase is mostly seen in people aged 80 and over. Unfortunately, overall life expectancy is increasing faster than healthy life expectancy, i.e., the average number of years lived in good health. In our country, the trend in the older adult population is similar, with a projected increase in the number of people aged 65 and over. This dramatic shift in the population is expected to place further pressure on health services in both primary and secondary care. The older adult population is at least partly prone to multiple chronic conditions and is susceptible to polypharmacy, resulting in adverse drug reactions, given that clients take as many as 12 medications daily.

Defining the knowledge base

Aging is a gradual progressive process characterized by physiological changes and an observable decline in bodily functions together with increased susceptibility to adverse drug effects (Mangoni and Jackson 2003) p. 96. In addition to physiological decline, there are also age-related neurological deficits that may result in visual, motor and cognitive impairments, which can reduce quality of life and indeed hinder the individual's ability to take their medications safely. These changes affect the absorption, metabolism, distribution and elimination of drugs, which can be unpredictable and subject to significant variability among clients, but may ultimately lead to adverse drug reactions (Stegemann et al. 2010) p. 78. As a result, prescribing for this population should be carefully considered.

Analysis of the current state

Complex health conditions, long-term illnesses, multiple chronic diseases and geriatric syndromes affecting some older adults often require multiple drug therapy as a primary intervention for either treatment, prevention, control, or improvement of clients' quality of life. Given the changes in pharmacokinetics – from drug intake to drug elimination, and pharmacodynamics – the drug's effect on the body associated with age in this population, this leads to appropriate drug use.

Table 1 Changes in the population of people aged > 65 over the next 40 years in both developed and developing countries. (adapted from (Stegemann et al. 2010), p. 145.

This dramatic shift in the population is expected to place further pressure on health services in both primary and secondary care. The older adult population is at least partly prone to multiple chronic conditions and is susceptible to polypharmacy, resulting in adverse drug reactions.

When medications are administered to social service clients, their administration must be documented in Drug Records. Drug Records represent the primary documentary record of medication administration to clients. Each client should have a separate Drug Record, which provides details about the client including their name, date of birth and allergy status, contains a list of all medications to be administered to the client, with attached dosage instructions, any special instructions or safety precautions associated with the medications, and provides a grid in which administration reports are recorded. There is no uniformly defined format for the Drug Record; however, the content will be roughly similar, allowing efficient information about the client and subsequent recording of medication administration in the Drug Record.

Drug waste can occur at any stage of the drug management process, from issuing a prescription to the medication reaching the patient. It is also evident that both patients and healthcare workers (physicians, pharmacists, healthcare staff) contribute to drug waste. It is clear that some causes of drug waste can be prevented (e.g., preventing excessive medication stockpiling, promoting medication management compliance through patient education and counseling), while others cannot be prevented (e.g., death), with estimates suggesting that the split between preventable and non-preventable waste is approximately 50:50 (York Health Economics Consort and The School of Pharmacy 2010) p. 112.

Research rationale

The causes of polypharmacy are multifactorial, but the concept of prescribing cascades plays a significant role where an adverse drug reaction is misdiagnosed as a new symptom such that the physician prescribes for the first symptom of the disease rather than the underlying chronic condition, and drug B is prescribed instead of rationalizing drug A (Lavan and Gallagher 2016 p. 82; Cahir et al. 2010) p. 221. This is more complicated in the social service facility environment, where there are more sources of health services involved with numerous prescribers, such as general practitioners and specialist physicians, who often do not consult directly with the client but rather receive information about the client through a nurse or caregiver (Bergman et al. 2007) p. 96. In the social service home, patients are at level 6 in the provision of nursing care.

Estimates suggest that approximately 80% of all medications in social service facilities could be packaged in MSDL systems. MSDL is recommended for all medications including as-needed medications, medications with potential cytotoxicity, medications with variable dosing and hygroscopic or photosensitive medications. However, MSDL could be the most commonly used system in social service facilities or in home care for drug management.

Table 2 Pharmaceutical requirements for social service facilities

Source: Ministry of Health of the Slovak Republic: https://www.slov-lex.sk/pravne-predpisy/SK/ZZ/2005/501/#prilohy.priloha-prilohak_vyhlaske_c_501_2005_z_z.oznacenie

Methods used in the research

This section defines the methods to be used in the study. This article is part of a broader study aimed at examining the implementation of MSDL packaging. For a social service facility to be eligible for the research, it must be registered as a social service provider and primarily care for older adults. Identification of social service facilities will be carried out in two parts, with a total of 10 social service facilities. In the first part, facilities providing social services such as Social Service Homes will be included. In the second part, facilities for seniors will be selected.

For objective 1, the Beers Criteria (Beers et al. 1991) p. 94 will be used, as it is one of the most commonly used explicit criteria. The Beers Criteria are based on published reviews, expert opinions and consensus methods without clinical assessment of the presenting client. It identifies and groups medications that may be inappropriate for older adults into three categories: i) medications that older adults should avoid; ii) medications that exceed the maximum recommended daily dose; iii) medications that should be avoided in combination with multiple diagnoses.

Several criteria have been developed that attempt to categorize such inappropriate prescribing. These criteria are either explicit (a list of medications to be avoided or used with caution) or implicit (based on physician judgment). In this study, the Beers Criteria were used, which are explicit criteria suitable for use in social service facilities with continuous health care. The head nurse in a social service facility is responsible for each client and works closely with physicians and specialists to ensure that social service recipients receive high-quality and professional nursing care.

The criteria categorize medications as: (i) those that older adults aged 65 and over should avoid (medications with high anticholinergic burden, i.e., medications that cause muscle receptor blockade and have side effects leading to further problems such as dry mouth, constipation, delirium, etc.); (ii) medications to be used with caution (independent of disease or condition, mainly aspirin for primary prevention of cardiac problems and diuretics that can ultimately cause increased sodium excretion from the body); and (iii) medications that should be avoided, particularly in disease conditions, where the nurse may inform the physician of the adverse effects of these medications for the client.

For the second objective, we will examine Drug Records of medications administered in social service facilities. The aim will be to identify errors associated with drug management in social service facilities. This can be achieved through numerous mechanisms including direct observation or document analysis (charts, clinical notes, etc.). Analysis of Drug Records has the advantage that it can be carried out directly in social service facilities, but depends on complete documentation. In the literature, there are no protocols that characterize errors in Drug Records, and therefore an internal protocol was developed to serve for the evaluation of drug records and drug management in social service facilities. Using a "pilot" facility and historical Drug Records, a protocol will be developed and refined that captures errors in five main categories:

  • regulatory errors,
  • administrative errors,
  • Drug Record errors,
  • stock errors and
  • miscellaneous errors.

Then analysis of ten social service facilities will be carried out and the error rate within drug administration and record-keeping will be calculated.

For the third objective, we will use a procedure in which participating social service facilities will be asked for records of returned medications and medications in the facilities will be physically counted and then compared with the documented medication status. The value of returned medications and excess medications will then be calculated using a simple formula for estimating the rate of drug waste.

Cost of unused medications = Unit price × Unused quantity (Ciullo and Shepherd, 1977).

Validity

The validity of the information obtained is very high, given that records will be collected from individual social service facilities that express interest in participating in this type of study. The information obtained will contribute to improving drug management in social service facilities, individualizing client needs and, within the findings on drug waste, we will contribute to improving the expenditure of financial resources on medications and reducing the accumulation of excess medications in these facilities.

Sampling

Selection of social service facilities will be carried out by sampling from available facilities. The sampling methodology will be chosen in collaboration with a research worker. For a social service facility to be eligible for the study, it must primarily provide social services to older adults. An additional criterion will be that the facility uses some form of Drug Record for documenting medication management and that care is primarily provided for older adults.

Research timeline

Research on this topic already began in 2014, with the expectation of completing the research and publishing the research results in 2021.

Procedure

Statistical analysis of the data will be carried out based on available data using the EXCEL software package, utilizing its extended functions.

Data processing methods

Accurate and practically verified statistical data processing methods will be used in data collection, based on methods of:

  • data sorting,
  • creation of data classes,
  • categorization of medication errors, drug waste,
  • creation of graphs from available data.

Data collection

Data for our research will be obtained by collecting Drug Records from the selected social service facilities in anonymized form, so that any part of the Drug Record that could identify clients is anonymized. Medications prescribed for each client will be extracted directly from the Drug Records using retrospective analysis of anonymized drug records and classified according to therapeutic categories. Information extracted from the Drug Records should include: i) date of birth; ii) medication name (drug group); iii) medication dosage (data such as g, mg, mcg, etc.); iv) formulation type (before meals, after meals); v) prescribed dose of active ingredient; vi) administration frequency; vii) amount received; viii) type of medication, i.e., whether it is a regular medication or an "as-needed" medication ("as-needed" medication is taken irregularly, such as for headaches, etc.).

Within the second objective, the same Drug Records will be used to examine the types and prevalence of errors in social service facilities during medication administration.

Within the third objective, we will examine records from selected social service facilities regarding drug waste (drug waste audit) to determine the actual state of drug waste.

Research hypotheses

We focused our research on verifying three hypotheses: H1: The most frequently inappropriately prescribed medications are laxatives and paracetamol for older adults living in social service facilities, as a result of inappropriate drug prescribing due to poor drug management, where long-term medications are prescribed by physicians without further necessary examinations. H2: The most common medication administration errors are missed doses. H3: In social service facilities, we have more excess medications than medications returned to pharmacies.

Study implementation procedure

The implementation of the study assumes several sequential stages:

  1. Selection of social service facilities.
  2. Collection of anonymized Drug Records.
  3. Data collection from Drug Records for each client of the social service facility.
  4. Audit of drug waste and medications returned to pharmacies.
  5. Administration of the collected data and additional accompanying methodologies.
  6. Mathematical and statistical processing of data from the collected Drug Records and medication return records, and subsequently for verifying the other formulated hypotheses.
  7. Interpretation of the findings, discussion, conclusion, recommendations for practice.

Results (Expected results)

We expect that through our research we will arrive at the following solutions:

  1. The research results will be related to problems in drug prescribing, administration and waste in social service facilities. Although this is not explicitly tested, the identified problems may result in harm to clients' health and are likely to further constrain health and social care resources. Social service recipients are a particularly vulnerable population, and efforts to strengthen or introduce a multidisciplinary approach to health and social care for these clients should be renewed.
  2. Currently, our system does not enable healthcare professionals to effectively collaborate in client care, and therefore pharmaceutical care for social service recipients is not optimal.
  3. The solution for optimizing drug management is close cooperation between pharmacists and social service facility managers in the efficient packaging of medications using the Drug Monitoring System MSDL.

Expected research outputs:

We expect verification of all three hypotheses. This will demonstrate the unsustainability of the current situation and the necessity of adopting a new solution to the problem. The new solution must be designed on the basis of thorough analysis: a) A medication packaging system both inside and outside social service facilities, directly by qualified pharmacy personnel b) The subsequent ability for such packaged medications to be administered by caregivers as well c) Less drug waste and reduced excess medications in social service facilities d) A system focused on drug management efficient for every patient/client.

For all systems, a comparative analysis of the advantages and disadvantages of each of these systems must be developed to propose an amendment to the law with the following parameters: a) drug management b) effective drug prescribing (communication among professionals) c) packaging medications in hermetically sealed containers (MSDL) directly by pharmacists at dispensing d) drug and drug waste audit e) prevention of accumulation of excess medications in social service facilities.

Output

Preparation of analyses to serve the social and health sectors to justify changes in drug management in Slovakia. Currently, this system does not enable healthcare professionals to effectively collaborate in client care, and therefore pharmaceutical care for social service recipients is not optimal. However, MSDL could be the most commonly used system in social service facilities or in home care for drug management.

Outputs – discussion of research benefits

In the discussion upon completion of the study, we will publish the application of research results to real life with calculation of efficiency and benefits, mainly for:

  • Drug management and effective drug prescribing.
  • Reduction in prescribing potentially inappropriate medications.
  • Drug Monitoring System and drug audit.
  • Reduction of drug waste in social service facilities.

In this section of the study, we will compare the results of this work with results of similar work abroad, as well as similar research in Slovakia. In the discussion, we will address the following problem areas:

  • In what ways our research agrees with other research and investigation of the causes of agreement.
  • In what ways our research disagrees with other research and investigation of the causes of disagreement.
  • What entirely new, previously unpublished facts, realities and proposals were brought forward.
  • What confirmed already established findings from similar work and research.

Research outputs

As outputs from this work, materials will be prepared for effective drug management and medication packaging in hermetically sealable containers (MSDL). The outputs will be as follows: a) A completed dissertation prepared for defense. b) Publication of partial research outputs at professional scientific conferences. c) Publication of partial research outputs in professional scientific journals. d) Publication of the work results as an independent scientific monograph.

Through this research, we can demonstrate how resource-intensive it is to analyze Drug Records. Realistically, this must be carried out by a healthcare professional with experience in the use of medications (pharmacist, physician, etc.). If institutions are to better understand the issues of drug management in social service facilities, collaboration with facilities is necessary in developing key performance indicators and related indicators to better monitor compliance with standards. This is in the interest of clients, social service facilities and regulators alike.

Author: PhDr. Bc. Marcel Tóth The author of this professional article is a doctoral student at the University of Health and Social Work of St. Elizabeth in Bratislava.

References:

  1. ALLDRED, D. and STANDAGE, C. 2011. Medication errors in care homes. Nursing Times 107 (24), pp. 14–15.
  2. ALLDRED, DP et al. 2007. Antipsychotic prescribing patterns in care homes and relationship to dementia. Psychiatric Bulletin 31 (09), pp. 329-332.
  3. ANRYS, PMS et al. 2018. Potentially inappropriate prescribing in Belgian nursing homes: prevalence and associated factors. Journal of American Medical Director Association 19 (10), pp. 884–890.
  4. AVORN, J. and GURWITZ, JH 1995. Drug use in long-term care facilities. Annals of Internal Medicine 123 (3), pp. 195–204. All Wales Medicines Strategy 2017. National Prescribing Indicators 2017-2018 [online] Available at: http://www.awmsg.org/docs/awmsg/medman/National%20Prescribing%20Indicators%202013-2014.pdf [Accessed: 30 October 2018].
  5. BALLENTINE, NH 2008. Polypharmacy in older adults. Critical Care Nursing Quarterly 31 (1), pp. 40-45.
  6. BARBER, ND et al. 2009a. Study on medication use in care homes: prevalence, causes and potential harm of medication errors in care homes for older people. Quality and Safety in Health Care 18 (5), pp. 341–346.
  7. BARBER, ND et al. 2009b. Study on medication use in care homes: prevalence, causes and potential harm of medication errors. Quality and Safety in Health Care 18 (5), pp. 341–346.
  8. BATES, DW 2007. Prevention of medication errors: An overview. Am J Health-Syst Pharm. 64 (9), pp. S3-S9.
  9. BEERS, M. et al. 1988. Psychoactive drug use in nursing home residents. JAMA: The Journal of the American Medical Association 260 (20), pp. 3016 - 3020.
  10. BEERS, MH et al. 1991. Explicit criteria for determining inappropriate drug use in nursing home residents. Archives of Internal Medicine 151, pp. 1825–32.
  11. BELOOSESKY, Y. et al. 2013. Rate, variability, and associated factors of polypharmacy in nursing home patients. Clinical Interventions in Aging 8, pp. 1585–90.
  12. BERT, S. et al. 2012. Evaluation of medication administration errors in a university hospital. BMC Health Services Research 12 (1), pp. 60–8.
  13. BERRY, SD et al. 2016. Antipsychotic and benzodiazepine drug changes affect acute fall risk in nursing homes: Genograms and phenotypes in the elderly (GPE) study. Journals of Gerontology Series A Biological Sciences and Medical Sciences 71 (2), pp. 273–278.
  14. BIERMAN, AS et al. 2007. Sex differences in inappropriate prescribing among elderly veterans. American Journal of Geriatric Pharmacotherapy 5 (2), pp. 147 - 161.
  15. BIRON, A., 2009. The complexity of medication management, work interruptions, and nurse workload as predictors of medication administration errors (doctoral dissertation, McGill University).
  16. CADOGAN, C. et al. 2015. Delivering appropriate polypharmacy for older people in primary care: a qualitative, theory-based study of community pharmacists' perceptions and experiences: 0032. International Journal of Pharmacy Practice, 23, pp. 32
  17. CAHIR, C. et al. 2010. Potentially inappropriate prescribing and cost outcomes for older people: a national population study. British Journal of Clinical Pharmacology 69 (5), pp. 543–52.
  18. CARAYON, P. et al. 2014. Characterising the complexity of medication safety using a human factors approach: an observational study on two intensive care units. BMJ Quality & Safety 23 (1), pp. 56–65.
  19. COLLARD, RM et al. 2012. Prevalence of frailty in community-dwelling older persons: A systematic review. Journal of the American Geriatrics Society 60 (8), pp. 1487–1492.
  20. COOPER, JA et al. 2015. Interventions to improve appropriate polypharmacy in older people: a Cochrane systematic review. BMJ Open 5 (12), pp. 1-11.
  21. CRESPIN, DJ et al. 2010. Medication errors in a long-term care facility: incidence rates and contributing factors. American Journal of Geriatric Pharmacotherapy 8 (3), pp. 258-270.
  22. DAWARE, MA 2014. Article Summary: Osteoporosis in the elderly. Vidarbha Journal of Internal Medicine 17 (July), pp. 19–27.

Related article

Drug Monitoring System (MSDL) suitable for people who take long-term medication in social facilities and at home