Underlying risk factors for prescribing errors in long-term aged care: A qualitative study

Tariq, Amina, Georgiou, Andrew, Raban, Magdalena, Baysari, Melissa Therese, & Westbrook, Johanna (2016) Underlying risk factors for prescribing errors in long-term aged care: A qualitative study. BMJ Quality and Safety, 25(9), pp. 704-715.

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  • To identify system-related risk factors perceived to contribute to prescribing errors in Australian long-term care settings, that is, residential aged care facilities (RACFs).

Design and setting

  • The study used qualitative methods to explore factors that contribute to unsafe prescribing in RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May and November 2011. Participants included RACFs managers, doctors, pharmacists and RACFs staff actively involved in prescribing-related processes. Methods included non-participant observations (74 h), in-depth semistructured interviews (n=25) and artefact analysis. Detailed process activity models were developed for observed prescribing episodes supplemented by triangulated analysis using content analysis methods.


  • System-related factors perceived to increase the risk of prescribing errors in RACFs were classified into three overarching themes: communication systems, team coordination and staff management. Factors associated with communication systems included limited point-of-care access to information, inadequate handovers, information storage across different media (paper, electronic and memory), poor legibility of charts, information double handling, multiple faxing of medication charts and reliance on manual chart reviews. Team factors included lack of established lines of responsibility, inadequate team communication and limited participation of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors related to staff management and workload included doctors’ time constraints and their accessibility, lack of trained RACFs staff and high RACFs staff turnover.


  • The study highlights several system-related factors including laborious methods for exchanging medication information, which often act together to contribute to prescribing errors. Multiple interventions (eg, technology systems, team communication protocols) are required to support the collaborative nature of RACFs prescribing.

Impact and interest:

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ID Code: 95865
Item Type: Journal Article
Refereed: Yes
Keywords: Prescribing, aged care, system factors, medication safety
DOI: 10.1136/bmjqs-2015-004589
ISSN: 2044-5423
Divisions: Current > QUT Faculties and Divisions > Faculty of Health
Current > Schools > School of Public Health & Social Work
Copyright Owner: Copyright 2015 Article author (or their employer)
Deposited On: 30 May 2016 23:32
Last Modified: 30 Sep 2016 07:44

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