Steps for reducing medication harm

Medication-related issues remain a hot topic in residential aged care. They continue to feature at the top of the most common complaints list. They have also been brought up frequently at the aged care royal commission. 

One of the challenges is that residents’ medication regimens are becoming increasingly complex, says Professor Simon Bell, director of Monash University’s Centre for Medicine Use and Safety (CMUS).

“Multi-morbidity and frailty is highly prevalent in a residential aged care setting. That means residents use multiple medications, and along with an increasing number of medications goes the increased potential for medication related harm,” Bell tells Australian Ageing Agenda.

Another factor is that residents have changing goals of care. It is important to ensure a medication regimen is consistent with the current goal of care, which requires medication literacy, he says.

“Often when it is not we find that the risks of medications may outweigh the benefits for certain conditions,” Bell says. “Medications that were once appropriate medications and have had a benefit for people may no longer be necessary in the residential care setting.”

But equally there may be a focus on different issues such as maintaining quality of life or symptom management, he says. “It is important that people aren’t deprived of medicines that might benefit as well.”

Bell says a facility’s medication advisory committee is important in this individualised approach because it is able to interpret local data to inform local decisions to improve the use of medication.

Under the Australian Government’s Guiding principles for medication management in residential aged care facilities (2012), every aged care home should have access to either a local or regional medication advisory committee.

“But we have found the structure and function of those medication advisory committees can vary quite a lot from provider to provider,” says Bell.

A recent CMUS study investigated residential aged care medication advisory committees. An expert panel then made 12 recommendations for optimising residential aged care medication advisory committees are:

The research, which was funded by the Victorian Government Department of Health and Human Services, involved interviews and focus groups with health professionals from 27 government-run aged care homes across four health services in rural and regional Victoria.

While the study focused on government-run facilities, the findings, principles and recommendations can be applied broadly across the aged care sector, says Bell.

All the MACs investigated in the study had a solid focus on quality use of medicines and a strong desire to improve the safe and effective use of medicines. However, the composition of medication advisory committees and how they approached quality use of medicines was quite different, he says.

“One of key findings was the opportunity to share strategies to improve the quality use of medications with different medication advisory committees,” Bell says. “The research highlighted the importance of medication advisory committees proactively identifying emerging quality use of medicines issues and then responding to those issues.”

He says there’s particular value in a multidisciplinary committee to bring together different perspectives for improving the quality use of medicines, including the accredited pharmacist who conducts the residential medication management reviews.

“We know that engaging all stakeholders is important to ensure optimal medications use. So that includes nurses, general practitioners, pharmacists and residents and carers as well.”

All members of the committee should be empowered to ask questions and contribute to improve the use of medications, he says.

“It is about bringing the team together and recognising that every member of the medication advisory committee makes an important contribution. And a different contribution. That is going to be very important in terms of being able to identify and proactively respond to emerging issues.”

Importantly, the medication advisory committee is well-placed to advise on local strategies based on interpretation of local data for improving medication management, such as reducing medication-related harm, Bell says.

“So that could translate to fewer medication errors or better monitoring and better information about use of high risk medications. And that can hopefully minimise the incidents of medication relation problems among residents.”

Optimising your MAC

The expert panel’s recommendations for optimising residential aged care medication advisory committees (MAC) are:

1. The MAC should have clear terms of reference and an agenda that is consistent with the example provided in the Guiding principles for medication management in residential aged care facilities (2012) , including a focus on emerging clinical and safety considerations.
2. Consideration should be given to appointing an independent chair of the MAC, such as the consultant pharmacist, for the purposes of clinical governance, accountability and transparency.
3. If a MAC is broader in scope than aged care, there should be standing agenda items related to aged care and sufficient time allocated to adequately address aged care specific quality use of medicines (QUM) issues.
4. All MACs should have a resident and family carer representative to ensure residents’ rights, concerns and priorities are proactively addressed.
5. Each MAC should be multidisciplinary and, in addition to senior residential aged care staff, should include at least one general medical practitioner, pharmacist and nurse involved in direct resident care. Consideration should be given to including the community and consultant pharmacist.
6. Flexible meeting times and format should be considered to maximise participation by external personnel. Meeting times may be set to coincide with GP or pharmacist availability, such as breakfast meetings. When relevant, telephone or video conferencing should be used to maximise participation.
7. MACs should actively seek and promote examples of best practice. This includes facilitating networking opportunities for members, and recruiting members whose work extends to other residential aged care services, MACS or regions so they are able to share their experiences and insights.
8. The MAC should have an efficient mechanism for ratification of new initiatives, and position descriptions and expectations for internal and external members.
9. The MAC should lead and facilitate QUM education of staff, residents and family carers, including the recording of staff training and attendance. The MAC may facilitate prescriber education related to QUM principles in aged care. These roles could be performed in liaison with an education officer or committee as appropriate.
10. The MAC should advise on best available medication information resources and ensure that these resources are made available to staff, visiting GPs and, when relevant, consumers and family carers.
11. Quarterly medication indicators, e.g. polypharmacy, proton- pump inhibitors, antipsychotics, and more than four administration times, along with medication incident reports and other medication related matters should be tabled and discussed at every MAC meeting. These data should be utilized by the MAC to identify and prioritize areas for local and regional quality improvement initiatives to reduce potential medication-related harm.
12. The MAC should oversee monitoring and evaluation of high-risk medications, and ensure that staff, residents and family carers are trained to identify and report common and potentially serious adverse drug events associated with these medications. High risk medications may be added as a standing agenda item. The consultant pharmacist should consider presenting and discussing QUM issues identified during RMMRs conducted during the previous quarter.

The research and expert panel recommendations are published in paperThe role of medication advisory committee in residential aged care services in Research in Social and Administrative Pharmacy .

This article appears in the current edition of Australian Ageing Agenda magazine (Mar-Apr 2020).

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