Residents in care homes with dysphagia found to be almost twice as likely to experience medication administration errors as those without

A small-scale observational study in six care homes with 166 residents in Northern England identified from observing 738 individual medication administrations, an error rate of 57.3% in those with dysphagia compared to 30.8% in those without.(1) The main differences in the reasons for errors seen in the residents with dysphagia were drug omission, incorrect performance in drug administration and inappropriate prescribing.  Signs of aspiration were witnessed in 20% of residents with dysphagia during drug administration suggesting that the formulation may not have been optimised.

The authors suggest that the omission errors may have resulted from the observation by a pharmacist and nurses choosing not to administer a medicine to a resident with dysphagia rather than administer it incorrectly. It could be seen however that administrations to residents with dysphagia were frequently incorrect and this was believed to the additional complexity which dysphagia adds to the administration process.  Inappropriate prescribing was determined largely because residents had swallowing problems, which had probably not been communicated to the prescriber, and therefore the formulation selection was unlikely to be ideal.

The authors suggest that nurses and carers should be observed regularly when administering medicines to enable solutions to improving medicines administration performance to be identified and implemented.

  1. Serrano Santos JM, Poland F, Wright D, Longmore T. Medicines administration for residents with dysphagia in care homes: A small scale observational study to improve practice. International journal of pharmaceutics. 2016;512(2):416-21.