Medicines administration for residents with dysphagia in care homes: A small scale observational study to improve practice

Serrano Santos, Jose Manuel, Poland, Fiona, Wright, David.J., & Longmore, Timothy (2016) Medicines administration for residents with dysphagia in care homes: A small scale observational study to improve practice. International Journal of Pharmaceutics. (In Press)

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  • In the UK, 69.5% of residents in care homes are exposed to one or more medication errors and 50% have some form of dysphagia. Hospital research identified that nurses frequently crush tablets to facilitate swallowing but this has not been explored in care homes. This project aimed to observe the administration of medicines to patients with dysphagia (PWD) and without in care homes.


  • A convenient sample of general practitioners in North Yorkshire invited care homes with nursing, to participate in the study. A pharmacist specialised in dysphagia observed nurses during drug rounds and compared these practices with national guidelines. Deviations were classified as types of medication administration errors (MAEs).


  • Overall, 738 administrations were observed from 166 patients of which 38 patients (22.9%) had dysphagia. MAE rates were 57.3% and 30.8% for PWD and those without respectively (p < 0.001). PWD were more likely to experience inappropriate prescribing (IP). Signs of aspiration were more frequently observed in PWD when IP occurred (p < 0.001).


  • Observation of medication administration practices by independent pharmacists may enable the identification of potentially dangerous practices and be used as a method of staff support. Unidentified signs of aspiration suggest that nurses require training in dysphagia and need to communicate its presence to the resident’s GP. Further research should explore the design of an effective training for nurses.

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ID Code: 96524
Item Type: Journal Article
Refereed: Yes
Keywords: Medicines, Dysphagia, Swallowing difficulties, Prescribing, Medicines administration, Care home with nursing, Nursing home, Deglutition, Deglutition disorders
DOI: 10.1016/j.ijpharm.2016.02.036
ISSN: 0378-5173
Divisions: Current > Schools > School of Clinical Sciences
Current > QUT Faculties and Divisions > Faculty of Health
Current > Institutes > Institute of Health and Biomedical Innovation
Copyright Owner: Copyright 2016 Elsevier
Deposited On: 04 Jul 2016 23:56
Last Modified: 26 Jul 2016 16:19

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