Residential care pharmacists: another hole plugged in the Swiss cheese

Medication management in residential aged care homes (RACHs) is a complex system, requiring multifaceted strategies to optimise the safety and quality of medicine use in this setting. Older adults encounter numerous healthcare professionals, systems and processes as they transition from home, between multiple hospital wards, to intermediate care facilities and to RACHs. Transitioning from the community or hospital into RACHs has been identified as a particularly high‐risk point for medication misadventure.Factors that increase the risk of a potentially harmful medication error during care transfer are inadequate communication, polypharmacy and a lack of onsite pharmacy services.Communication failure between different points of care and care providers is cited as the leading cause for transition‐related medication errors. Poorly executed care transitions and miscommunications can result in fragmentation of care and potentially serious adverse drug events, which may require hospital admission. Existing systems within RACHs to prevent medication‐related miscommunication may not be sufficiently structured to identify missing or incorrect information. Providing an additional barrier in the form of a medicines expert may help prevent communication failure and subsequent medication errors from occurring when gaps in existing RACH safeguards align. Preventable adverse drug events account for up to 56% of all reported care transition medication errors.8 Approximately 20% of residents experience a significant delay in medication administration and missed doses following transfer to an RACH.3 Transition‐related medication errors are observed for 13–31% of RACH residents, often involve high‐risk medications such as anticoagulants and opioids, and have a greater risk of causing serious resident harm.5 Anticoagulants such as warfarin are classified as high‐risk medicines due to a narrow therapeutic index and potential for serious haemorrhagic or thromboembolic events if therapy falls above or below the therapeutic range, respectively. Warfarin is one of the most commonly implicated drugs in RACH adverse events and should be carefully reviewed during care transitions. Pharmacist‐led medication reconciliation at the point of transfer to and from RACHs likely improves medication‐related outcomes for residents. Pharmacists are ideal candidates to facilitate timely medication reconciliation to support safe management of the complex multidrug regimens often seen in RACH residents.10 Pharmacists may help minimise the risk of medication error by supporting communication, education, appropriate administration practices and adjustments to new medication regimens. Therefore, residents transitioning to RACHs have been identified as good candidates for receiving timely pharmacist review. The following case vignettes, listed under pseudonyms, were documented by one of the authors (RT) while employed part‐time as a residential care pharmacist (RCP) during a 6‐month trial as part of a broader study. (This research was approved by the University of Canberra Human Research Ethics Committee (HREC 16–244).) The RCP role involved the integration of an accredited pharmacist into an established RACH. The RCP was an in‐house pharmacy service, as opposed to the consultancy‐based visitational role currently provided. This integrated service was intended to enhance the efficiency of follow‐up with residents and care providers as required, facilitate more frequent face‐to‐face collaboration between the pharmacist and care team, enhance understanding of resident‐specific medication management decisions and improve understanding of site‐specific operational policies and procedures. The cases below exemplify the RCP service within RACHs to reduce medication errors during transitions of care. These cases were selected because they were the most comprehensive data sets, and the clinical context for each had the potential for severe consequences. Active follow‐up (when required) of residents at ongoing risk of medication misadventure was unique to this role.