How accurate are manually prepared dose administration aids in residential aged care facilities?

Background: Use of dose administration aids (DAAs) in Australian aged care facilities (ACFs) is common, having been adopted as a means of reducing medicine errors and increasing the efficiency of medicine administration. Aim: To audit a sample of manually prepared DAAs in an aged care setting and determine the rate of discrepancies between the contents of the DAA and the medicine chart. Method: A student researcher conducted audits at two ACFs. Incidents were documented and reported to nursing and pharmacy staff. In consultation with two academic pharmacists, incidents were categorised according to type, medicine class; potential medicine related problem; and whether they were actual errors. The primary outcome measure was the rate of errors per number of DAAs audited. Results: One hundred and sixty-six DAAs, containing 617 medicines, prepared for 91 residents were audited. Nineteen incidents were recorded, 18 of which were actual errors, which equates to a rate of 1 error per 5.1 patients, per 9.2 DAAs or per 34.3 medicines. Conclusion: The rate of errors (10.8 of DAAs) was higher than those observed previously, indicating a need for further investigation to confirm these results, determine possible causes for errors and develop methods to minimise their occurrence.