Title: Root causes of adverse drug events in nursing home residents with diabetes: enhancing safety in medicines management
Funder: Department of Health (England)

Abstract: Background Improvements in patient safety are central to the Quality Innovation Productivity and Prevention (QIPP) project of the NHS. Adverse drug events (ADEs), such as drug prescribing and administration errors, dispensing problems and adverse drug reactions, are a significant and common cause of patient safety incidents in all health and social care settings. Such events carry significant human and financial costs. Diabetes mellitus is an increasingly common high impact health problem in the UK affecting an estimated 2.6 million people and up to 26% of the care home population (Sinclair & Asprey 2009). The evidence base in terms of understanding the incidence, causes and severity of ADEs is stronger in the healthcare setting with less being known about nursing home provision. Aims With regard to nursing home residents with diabetes and NHS medicines services: - Identify, describe and analyse adverse drug events linked to NHS provision occurring in nursing homes - Conduct a critical analysis of the moderate to potentially severe harm incidents and feed this back to the relevant providers - Combine this data in a meta-root cause analysis constructing a qualitative overview of the identified causes of the errors - Develop risk assessed strategies, solutions and applied learning through which the number and severity of adverse drug events in this patient group can be reduced - Provide a model and guidelines upon which the management of medications between NHS provision and nursing homes can be improved. Plan of Investigation - Recruit participating nursing homes and identify relevant adverse drug events (errors) - Construct a narrative description of those events and risk assess each using the NPSA risk matrix scoring system - Complete an anonymous narrative analysis and summary of the 'low' harm events and feed this back to relevant providers - Complete a Root Cause Analysis (RCA) of each of the 'moderate' to 'extreme' risk events and feed this back to the relevant health and social care providers as individual, confidential reports - Subject the sample of 25 RCAs to a meta root cause analysis - Utilise that data to construct relevant reports and solution development for NHS providers and those delivering nursing home provision -Provide data upon which NHS commissioning decisions can be made. Potential Impact There is clear evidence that ADEs are a significant cause of preventable harm to those in social care. The Care Home Use of Medicines study (Barber et al 2009) concluded that two thirds of care home residents were subject to one or more medication errors. Reductions in the number of these errors in the nursing home setting will: 1/ Improve the quality and safety of residents with diabetes 2/ Improve staff moral and working practices as developments in patient safety improve efficiency and care delivery systems 3/ Reduce costs through the improved utilisation of medicines and savings in staff time 4/ Enhance NHS medication management and reconciliation between health and social care sectors 5/ Reduce re-admissions to hospital that are due to avoidable medication incidents in nursing homes.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: METABOLIC AND ENDOCRINE