A review of coronial investigations into medication-related deaths in Australian residential aged care

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Background: Residential aged care is a complex and challenging clinical setting where medication errors continue to occur despite efforts to improve medication safety. No studies have sought to review and synthesize coronial investigations into medication-related deaths in Australian residential aged care facilities (RACFs). Objective: To review coronial investigations into medication-related deaths in Australian RACFs. Methods: A national review of medication-related deaths between July 2000 and July 2013 reported to Australian Coroners was performed. Data were extracted from the National Coronial Information System and errors categorized according to stages of the medication management cycle. Results: The database search identified thirty coronial investigations into deaths. Single medication classes were implicated in 22 deaths; including opioids (n = 7), antipsychotics (n = 4) and antidepressants (n = 3). Eight deaths resulted from two or more medication classes. Thirteen deaths reported stages of medication errors, including administration (n = 9) and monitoring (n = 4). Coroners made recommendations following three deaths; including education and training on dose administration aids, regulation of personal care workers, and protocol-based renal function monitoring for residents taking digoxin. Conclusions: Deaths involving high-risk medications occurred primarily at the stages of administration and monitoring. Few investigations resulted in specific recommendations, however it is unknown whether these were implemented.

Original languageEnglish
Pages (from-to)410-416
Number of pages7
JournalResearch in Social and Administrative Pharmacy
Issue number4
Publication statusPublished - Apr 2019


  • Coroner and medical examiners
  • Long-term care
  • Medication errors
  • Nursing homes

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