Many in Singapore nursing homes take wrong medication, dosage

Pharmacists found 392 medication issues among the 480 patients they reviewed
By Salma Khalik, Senior Health Correspondent, The Straits Times, 5 Oct 2015

Three in five nursing home patients could be taking medication in the wrong dosage or, sometimes, wrong medication altogether.

Not only is this putting them at higher risk of falls and heart problems, but it could also be costing them more.

A review of patients in three nursing homes by pharmacists from the National Healthcare Group (NHG) found that the 480 patients had 392 medication issues between them.

Some had more than one issue, especially those who were taking many different medicines. Some patients were taking as many as 20 different types of medicine.

The review findings were published in an article in the September edition of the Singapore Medical Journal.

The pharmacists identified, among other things, 66 patients who were receiving wrong doses, 46 who had untreated conditions and 64 who were on medicine they did not need, over a six-month period.

As a result, 60 patients were at higher risk of falls because of the medicines they were taking; 49 had constipation, largely caused by prolonged use of antihistamines for the treatment of itch; 66 had poor cholesterol or diabetes control and 31 suffered from anaemia.

The pharmacists decided to do the review because similar studies overseas had shown that, in nursing homes, having too many or inappropriate medicines increased costs, drug interactions, adverse effects and hospitalisation.

Ms Chia Hui Shan, a senior pharmacist at Jurong Polyclinic and the lead author of the article, said the same appears to be happening here.

In the article, the pharmacists suggested: "Physicians and nurses may face some initial challenges in this new collaboration; this may especially be the case for physicians, who may feel that their prescribing practices are being unfairly questioned."

The NHG review, done in 2011, wanted to determine if nursing homes would accept pharmacists' recommendations on medication and what it would cost to involve pharmacists in such homes.

So, the researchers checked if their advice was being followed, six months later.

They found that acceptance varied from 36 per cent at one nursing home to 74 per cent at another.

St Joseph's Home in Mandai Estate, one of three nursing homes reviewed, has continued getting a pharmacist in on a weekly basis to review the medicines its more than 120 patients are taking, as the scheme has helped patients, said Sister Gillian Beins, its assistant director of nursing .

She said: "Sometimes, doctors and nurses may overlook something that the pharmacist picks up. We should work as a team, with patients' welfare as priority."

The review found that the homes actually saved about $77 a month, even after paying for the pharmacist. It added that savings would be higher if indirect cost savings - such as from lower hospitalisation rates and better management of under-treated or untreated conditions - were taken into account.

Sister Beins said that even if it costs more, the home would be willing to bear the costs as it benefits patients by cutting down on side effects from necessary medicines.

Constipation is already a problem for seniors, and can be made worse with medications such as painkillers and antihistamines, she said.

These can also make patients drowsy and raise their risk of falling.

Ms Chia said the three homes reviewed were typical, and the same problems were likely to occur in all nursing homes.

As a result of the review and the positive response from nursing homes, the NHG now does medicine reviews for 20 nursing homes. Singapore has about 70 nursing homes.

* Enhancing medication safety for nursing homes

We share Ms Lim Lih Mei's views on the importance of medication safety ("Stringent checks needed on medication and dosage"; Tuesday) and assure her that efforts are being made to enhance medication safety in nursing homes.

As part of the Ministry of Health's (MOH) ongoing efforts to ensure that our seniors receive consistent and better quality of care, the Enhanced Nursing Home Standards (ENHS) were introduced as licensing terms and conditions in April this year, with a one-year grace period before enforcement begins next year in April.

Recognising the need for good pharmaceutical care in our nursing homes, we have strengthened the requirements for medication management within the ENHS.

In addition to the current requirement that only registered medical practitioners may prescribe residents' medication, the ENHS also state that medication reconciliation can be done only by such a practitioner, a registered pharmacist or an advanced practice nurse.

ENHS also require nursing homes to engage a registered pharmacist to visit at least once every six months to review the residents' medication and conduct audit checks on their medication management.

The study by the National Healthcare Group pharmacists was done in 2011 for only three nursing homes. In the four years since then, many more of our community care providers have taken positive steps to improve the quality of care, including in the area of pharmaceutical care, for their elderly residents and clients.

For example, the Agency for Integrated Care (AIC) has signed a memorandum of understanding with the Pharmaceutical Society of Singapore to provide pharmacist services for nursing homes to enhance their medication safety on a regular basis.

To date, 55 nursing homes have engaged the services of registered pharmacists for medication review.

AIC will continue to engage the rest of the sector to participate in this programme.

Eighteen nursing homes have also adopted pre-packed ready-to-administer sachet medications for patients, for greater reliability. Community care staff also attend annual training on prescription terminology, drug-related side effects and the use of medication for illnesses common among the elderly.

Ensuring that our seniors receive quality care and patient safety are priorities of MOH and AIC, and we continue to work closely with community care providers to improve standards of care.

Lim Bee Khim (Ms)
Director, Corporate Communications
Ministry of Health

Andy Seet
Director, Corporate and Marketing Communications
Agency for Integrated Care

ST Forum, 9 Oct 2015

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As many as three in five nursing home patients could be taking medication in the wrong dosage or, sometimes, wrong medication altogether, according to a review. str.sg/Z6MR
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