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Towards improving dose administration aid supply: a quality improvement intervention aimed at reducing dispensing errors


Background There is a risk that medicines can be dispensed into dose administration aids (DAAs), inaccurately or unsuitably. Quality improvement interventions (QIIs) may target this pharmacy medicine supply service and reduce the occurrence of these dispensing errors. In turn, medicine administration can improve in nursing homes (NHs) that use these devices. Objective To develop, introduce and evaluate the potential of a QII to improve DAA medicine supply. Setting Fourteen Victorian community pharmacies and 45 NHs. Methods A QII was developed using findings from three focus groups with 13 participants involved with DAAs at community pharmacies and NHs. The intervention was introduced to community pharmacies and NHs via a pharmacist-facilitated education session; attendees completed an evaluation questionnaire. Main outcome measure Potential usefulness and effectiveness of the QII at improving DAA supply and reducing dispensing errors. Results The QII was titled: ‘Be alert and work together for medicine safety, DAA incident awareness toolkit’. Four-hundred and thirty-five questionnaires were returned (85.0 % response rate). Respondents believed the intervention had the potential to improve pharmacy medicine supply or NH medicine administration involving DAAs ‘very’ (47.3 % of responses) or ‘extremely well’ (23.4 %). The intervention had the potential to reduce the occurrence of DAA dispensing errors ‘very’ (49.6 %) or ‘extremely well’ (20.5 %). Conclusion A stakeholder informed QII was perceived to have the potential to improve DAA medicine supply from community pharmacies to NHs and reduce the occurrence of dispensing errors found within them. Future quantitative evaluation of the intervention is required.

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  1. Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008. Aust N Z Health Policy. 2009;6(18):1–12.

    Google Scholar 

  2. Bond CA, Raehl CL. Pharmacists’ assessment of dispensing errors: risk factors, practice sites, professional functions, and satisfaction. Pharmacotherapy. 2001;21(5):614–26.

    Article  PubMed  CAS  Google Scholar 

  3. Flynn EA, Barker KN, Berger BA, Lloyd KB, Brackett PD. Dispensing errors and counseling quality in 100 pharmacies. J Am Pharm Assoc (2003). 2009;49(2):171–80.

    Google Scholar 

  4. Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc (Wash). 2003;43(2):191–200.

    Google Scholar 

  5. Knudsen P, Herborg H, Mortensen AR, Knudsen M, Hellebek A. Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Qual Saf Health Care. 2007;16(4):291–6.

    Article  PubMed  CAS  Google Scholar 

  6. Knudsen P, Herborg H, Mortensen AR, Knudsen M, Hellebek A. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care. 2007;16:285–90.

    Article  PubMed  CAS  Google Scholar 

  7. Peterson GM, Wu MSH, Bergin JK. Pharmacist’s attitudes towards dispensing errors: their causes and prevention. J Clin Pharm Ther. 1999;24(1):57–71.

    Article  PubMed  CAS  Google Scholar 

  8. Szeinbach S, Seoane-Vazquez E, Parekh A, Herderick M. Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. Int J Qual Health Care. 2007;19(4):203–9.

    Article  PubMed  Google Scholar 

  9. Teagarden JR, Nagle B, Aubert RE, Wasdyke C, Courtney P, Epstein RS. Dispensing error rate in a highly automated mail-service pharmacy practice. Pharmacotherapy. 2005;25(11):1629–35.

    Article  PubMed  Google Scholar 

  10. Teinila T, Gronroos V, Airaksinen M. Survey of dispensing error practices in community pharmacies in Finland: a nationwide study. J Am Pharm Assoc (2003). 2009;49(5):604–10.

    Google Scholar 

  11. Ashcroft DM, Quinlan P, Blenkinsopp A. Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies. Pharmacoepidemiol Drug Saf. 2005;14(5):327–32.

    Article  PubMed  Google Scholar 

  12. Gilmartin JFM, Hussainy SY, Marriott JL. Medicines in Australian nursing homes: a cross-sectional observational study of the accuracy and suitability of re-packing medicines into pharmacy supplied dose administration aids. Res Soc Adm Pharm. 2013:1–8. Epub doi: [Epub ahead of print].

  13. Carruthers A, Naughton K, Mallarkey G. Accuracy of packaging of dose administration aids in regional aged care facilities in the Hunter area of New South Wales. Med J Aust. 2008;188(5):280–2.

    PubMed  Google Scholar 

  14. Gerber A, Kohaupt I, Lauterbach KW, Buescher G, Stock S, Lungen M. Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany. Am J Geriatr Pharmacother. 2008;6(4):212–9.

    Article  PubMed  Google Scholar 

  15. Hussainy SY, Marriott JL, van Koeverden PM, Gilmartin JFM. How accurate are manually prepared dose administration aids in residential aged care facilities? A pilot investigation. Aust Pharmacist. 2012;31(4):320–5.

    Google Scholar 

  16. Roberts MS, Lentile C, Geoffrey L, Stokes J, Doran C, Hendry M, et al. Effectiveness and cost effectiveness of dose administration aids (DAAs) final report [online]. Quality Medication Care Pty Ltd, University of Queensland, Princess Alexandra Hospital, Australian Government Department of Health and Ageing, Pharmacy Guild of Australia; 2004. Available from: Accessed May 2013.

  17. Barber ND, Alldred DP, Raynor DK, Dickinson R, Garfield S, Jesson B, et al. Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual Saf Health Care. 2009;18(5):341–6.

    Article  PubMed  CAS  Google Scholar 

  18. Nguyen JK, Fouts MM, Kotabe SE, Lo E. Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents. Am J Geriatr Pharmacother. 2006;4(1):36–41.

    Article  PubMed  Google Scholar 

  19. Snowdon J, Day S, Baker W. Audits of medication use in Sydney nursing homes. Age Ageing. 2006;35(4):403–8.

    Article  PubMed  Google Scholar 

  20. Martin B, King D. Who cares for older Australians? A picture of the residential and community based aged care workforce 2007 [online]. Commonwealth of Australia; 2008. Available from:$File/who%20cares.pdf. Accessed May 2013.

  21. Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med. 2004;164:545–50.

    Article  PubMed  Google Scholar 

  22. Finkers F, Maring JG, Boersma F, Taxis K. A study of medication reviews to identify drug-related problems of polypharmacy patients in the Dutch nursing home setting. J Clin Pharm Ther. 2007;32(5):469–76.

    Article  PubMed  CAS  Google Scholar 

  23. Gurwitz JH, Field TS, Avorn J, McCormick D, Jain S, Eckler M, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109(2):87–94.

    Article  PubMed  CAS  Google Scholar 

  24. Pharmaceutical Society of Australia. Appendix 5: Examples of medicines which should not be packed in DAA. Pharmaceutical Society of Australia; 2007. Available from: Accessed May 2013.

  25. Llewelyn VK, Mangan MF, Glass BD. Stability of sodium valproate tablets repackaged into dose administration aids. J Pharm Pharmacol. 2010;62:838–43.

    PubMed  CAS  Google Scholar 

  26. Pharmaceutical Defence Limited, Australian Journal Of Pharmacy. Guide to good dispensing. Pharmaceutical Defence Ltd; 2010. Available from: Accessed May 2013.

  27. Australian Pharmaceutical Advisory Council. Guiding principles for medication management in the community. Canberra Commonwealth of Australia; 2006. Available from:$File/booklet.pdf. Accessed May 2013.

  28. Pharmaceutical Society of Australia. Professional practice standards. Australian Capital Territory: Pharmaceutical Society of Australia; 2010. Available from: Accessed May 2013.

  29. Ryan M, Huxhagen K, Jackson J, Kardachi G, Stokes J, Tsucalas D. Guidelines and standards for pharmacists—Dose Administration Aids Service. Pharmaceutical Society of Australia; 2007. Available from: Accessed May 2013.

  30. Pharmacy Board of Australia. Guidelines on specialised supply arrangements. Pharmacy Board of Australia; 2012. Available from: Accessed May 2013.

  31. HDG Consulting Group. Resource kit to enable implementation of the APAC guidelines for medication management in residential aged care facilities. Department of Human Services; 2006. Available from: Accessed May 2013.

  32. Australian Pharmaceutical Advisory Council. Guidelines for medication management in residential aged care facilities. Canberra: Australian Pharmaceutical Advisory Council; 2002. Available from:$File/resguide.pdf. Accessed May 2013.

  33. Australian Nursing Federation. ANF guidelines—the use of dose administration aids by nurses; 2008. Available from: Accessed May 2013.

  34. Australian Nursing Federation. ANF position statement—the use of dose administration aids by nurses; 2011. Available from: Accessed May 2013.

  35. Saini B, Smith L, Armour C, Krass I. An educational intervention to train community pharmacists in providing specialized asthma care. Am J Pharm Educ. 2006;70(5):1–10.

    Google Scholar 

  36. Nishtala PS, McLachlan AJ, Bell JS, Chen TF. Psychotropic prescribing in long-term care facilities: impact of medication reviews and educational interventions. Am J Geriatr Psychiatry. 2008;16(8):621–32.

    Article  PubMed  Google Scholar 

  37. Ray WA, Taylor JA, Meador KG, Lichtenstein MJ, Griffin MR, Fought R, et al. Reducing antipsychotic drug use in nursing homes, a controlled trial of provider education. Arch Intern Med. 1993;153:713–21.

    Article  PubMed  CAS  Google Scholar 

  38. Roberts MS, Stokes JA, King MA, Lynne TA, Purdie DM, Glasziou PP, et al. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001;51:257–65.

    Article  PubMed  CAS  Google Scholar 

  39. Maviglia SM, Yoo JY, Franz C, Featherstone E, Churchill W, Bates DW, et al. Cost-benefit analysis of a hospital pharmacy bar code solution. Arch Intern Med. 2007;167:788–94.

    Article  PubMed  Google Scholar 

  40. Poon EG, Cina JL, Churchill W, Patel N, Featherstone E, Rothschild JM, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med. 2006;145:426–34.

    Article  PubMed  Google Scholar 

  41. Halkin H, Katzir I, Kurman I, Jan J, Malkin BB-O. Preventing drug interactions by online prescription screening in community pharmacies and medical practices. Clin Pharmacol Ther. 2001;69:260–5.

    Article  PubMed  CAS  Google Scholar 

  42. Caldwell R, Oswald S. Dispensing error rate after implementation of an automated pharmacy carousel system. Am J Health Syst Pharm. 2007;64:1427–31.

    Article  PubMed  Google Scholar 

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The authors wish to thank Kerry Murphy and Souhiela Fakih for taking notes during the focus groups.



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Correspondence to Julia Fiona-Maree Gilmartin.

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Gilmartin, J.FM., Marriott, J.L. & Hussainy, S.Y. Towards improving dose administration aid supply: a quality improvement intervention aimed at reducing dispensing errors. Int J Clin Pharm 35, 1152–1160 (2013).

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  • Australia
  • Clinical interventions
  • Drug administration schedule
  • Drug packaging
  • Medication errors
  • Medication systems
  • Older adults
  • Pharmacy interventions