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Electronic medication administration records improve patient safety and reduce risk of human error at The Coach House Care Home for the Elderly.

The Coach House Care Home is a 21- bed residential home for the elderly in Garforth, Leeds. The home has residents on complex medication regimes. They invested in Omnicell eMAR after becoming aware of a number of issues with their medication rounds which was then further highlighted during a CQC inspection.

The goals of implementation were to...

  • Address concerns around medicines management highlighted during a CQC inspection.
  • Reduce the risk of human error during medication rounds, improving residents’ safety.
  • Improve the accuracy of drug counts and the time taken to do them.
  • Improve the audit trail of medication rounds and replace a cumbersome paper-based system.

Prior to Omnicell eMAR - CQC inspection report May 2017:

  • Gaps were seen in medication administration records and one person was given another person’s pain relief which was not the prescribed dosage.
  • Medication audits had not identified the concerns found during the inspection.
  • Medicines were not safely stored and administered.
  • Notes of when medicines were not administered were not routinely recorded on the back of the MAR.
  • PRN medicines were not given routinely and there was no guidance to help staff understand in which circumstances they should be offered.
  • Care and treatment was not provided in a safe way for people using the service because there was no safe management of medicines.

After Omnicell eMAR was implemented - CQC inspection November 2017:

  • Medicines were managed well and administration was safe. This meant the provider was now meeting legal requirements.
  • There were systems in place to ensure that medicines had been stored, administered and audited appropriately.
  • An automated medicines management and administration system had been introduced.
  • Staff spoke positively of the new system and explained it was safer and had been introduced to reduce errors in medicines management.
  • Each staff member, with responsibility for medicines, had their own sign in as an identity check and to record which staff member had administered the medicines.
  • The system prompted staff if there were any safety issues involved with the medicines about to be offered.
  • The system also timed the rounds to ensure people got their medicines at the correct time intervals and confirmed that all the medicines had been dispensed at the end of the round.
  • People’s electronic medicine administration records included a copy of their photograph and details of any known medicines allergies to help reduce the risks associated with medicines administration.
  • The eMARs showed people had received their medicines as prescribed and could also be accurately cross referenced with remaining medicines stocks to show that these were correct.
  • Staff were competent giving people medicines. They explained to people what their medicines were for and ensured each person had taken them before signing the medication record.
  • Staff had received training on the newly automated medicines management system. They said this training had been thorough and was supported by good back up support from the company who supplied the system. One staff member said; “It’s been brilliant, we all support each other but we also have someone we can speak to on the end of the phone. Any problems, they have been so helpful.”

Claire Buckle, Manager at Coach House Care Home commented, “The risk of human error during medication administration has been taken away since implementing Omnicell eMAR. For example, there is no longer the risk of overdosing patients as the system prompts you and tells you exactly when the resident had that last dose of medication. There has also been no incidents of missed medication errors since implementing the system. The audit trail is now much clearer as we no longer rely on a paper based system – in the event of discrepancies we can now see straight away what has happened and why it occurred. Stock counts are also much more accurate and quicker to do.”

Consultation has concluded