The case of a staff member at a Randers nursing home has led to a review of how care centers in the country handle medications, and the result is causing concern.
On Wednesday, a 60-year-old care home assistant in Randers was sentenced to 16 years in prison for four counts of attempted murder, after she gave residents of Plejecenter Tirsdalen medication they should not have been taking.
A report from the Danish Patient Safety Agency shows problems with the handling of medicines in many places.
At the request of TV 2, the agency reviewed all 98 investigative inspections carried out in Danish care centers in 2022, and in 70% of the inspections it became clear that there were problems with the handling of medicines.
The results of the inspection are stated in a press release from the Danish Patient Safety Agency.
- In 69 out of 98 nursing homes that underwent a thorough inspection in 2022, problems with medication handling were found.
- In 28 out of 98 nursing homes, the inspection concluded that there were serious deficiencies in patient safety, and 11 nursing homes ended up being classified in the worst category, “critical problems of importance to patient safety,” while 17 nursing homes ended up in the second worst category, “major problems of importance to patient safety.”.
- A total of 27 inspections resulted in a court order investigation or extension of a court order, representing 27.5% of cases.
- The review also shows that in every fourth inspection, there was a significant or serious deficiency in patient safety related to medication handling as part of the problems. These two categories are the most severe found in the inspections.
- According to the survey, 34 out of 67 nursing homes lack medication rooms, and medications are stored exclusively with the residents. Eleven of the 67 have medical rooms without a registration system, and nine of the 67 have different practices in individual nursing homes.
According to Charlotte Horth, chief physician and head of unit at the Danish Patient Safety Agency, the reasons for the classifications may be that residents are receiving the wrong medication, someone else's medication, or less or more medication than prescribed: “The reason it is dangerous is that some types of medication can cause many serious side effects and ultimately be fatal. Medications that should be given once a week may be given once a day, and this particular type of error can be dangerous.”.
Examples of failure to provide medication to inmates, according to the report
As an example of the problems, it turned out that an elderly person in a nursing home did not receive the heart medication he was supposed to take for four days, and neither the records nor the staff could explain why he was not given the heart medication.
During another inspection, the inspection department found that the drug had exceeded its expiry date by at least five months.
The review also shows that in every fourth inspection, there was a significant or serious deficiency in patient safety related to medication handling as part of the problems. These two categories are the most severe found in the inspections.
According to a survey conducted by kommune.dk, the trend is that newer nursing homes are providing the use of record systems, while there are many municipalities with older buildings that do not have record systems.
Examples of errors in medication administration
One example of the problems was a medication review that showed the patient had not received his heart medication for four days. Neither the records nor the staff could explain why the heart medication had not been administered.
During another inspection, the inspection department found that the product had exceeded its expiry date by at least five months.
During the inspection, the inspectorate found an insulin pen in the possession of a citizen whose expiry date had passed by seven months. During the inspection, the inspection department was unable to find the citizen’s morphine tablets in the citizen’s medicine box.
A sample also showed that staff at a care center were not instructed on how to administer insulin, as a sample of three records showed no documentation stating that the three citizens had received the medication they were supposed to take, and staff were unable to explain whether the diabetic patient had received the prescribed insulin. The inspectorate could find several gaps in the timetable for blood sugar measurements.
Source: Inspection reports from 2022, Danish Patient Safety Agency.
Charlotte Heuwert explains that mistakes can be due to a lack of skills, time constraints for the task, misunderstandings, or perhaps the appropriate instructions were not put in place for the employees.
