Introduction
In the evolving landscape of long-term care, ensuring resident safety while optimizing healthcare resources is paramount. Across Canada, health care aides (HCAs) play a vital role in providing direct care, and their responsibilities are continually being evaluated to meet the growing needs of the aging population. Within Alberta’s provincial continuing care system, medication assistance programs are a critical component of resident care. Understanding the safe and effective implementation of these programs, potentially guided by resources like an “Alberta Provincial Continuing Care Medication Assistance Program Map Manual,” is essential for quality care. While a specific “alberta provincial continuing care medication assistance program map manual” might be a resource of interest for operational guidance, this article delves into a crucial aspect of medication assistance: the safety of involving HCAs in oral medication administration within Alberta’s long-term care facilities. Concerns have been raised about potential increases in medication errors when non-nursing staff are involved in medication processes. This article addresses these concerns by examining a study conducted in Alberta, Canada, focusing on medication error rates associated with HCA involvement in oral medication assistance compared to other nursing staff in long-term care (LTC) settings. This analysis contributes to the broader discussion on workforce utilization, patient safety, and the effective delivery of medication assistance within the Alberta provincial continuing care framework.
Method: Investigating Medication Error Reporting in Alberta LTC Facilities
To assess the safety of health care aides (HCAs) assisting with oral medication administration, a comprehensive study was undertaken in Alberta, Canada. This research employed a mixed-methods approach, including a survey of 320 continuing care facilities and in-depth interviews at five facilities. This particular article focuses on the quantitative aspect, specifically analyzing medication error rates reported at two long-term care (LTC) facilities in Alberta.
The study utilized medication incident reporting (MIR) data from these two LTC sites to examine the types, severity, and frequency of medication errors involving different healthcare providers. Oral medication assistance was defined in alignment with Alberta guidelines as “a service provided to clients to ensure medication is taken as intended by the prescriber when the client is assessed as being unable to independently take his or her own medication safely.” This assistance can range from opening medication packaging to handing medications to residents for immediate consumption.
To evaluate the severity of medication errors, the study adopted a standardized rating scale, ranging from “no apparent harm” to “death.” For statistical analysis, error severity was categorized into two groups: “moderate harm” versus “less severe harm” (encompassing “minimal harm,” “no apparent harm,” “close call,” and “hazard”).
In addition to error reporting data, Resident Assessment Instrument (RAI) data was analyzed to understand the health status of residents in facilities where HCAs were involved in oral medication assistance. This included demographic information, health status indicators like the Changes in Health, End-stage disease, and Signs and Symptoms (CHESS) Scale, and pain scores. Data from two control LTC sites where HCAs were not involved in oral medication assistance was also accessed for comparison of resident populations.
Statistical analysis was performed using SPSS Version 19, employing Chi-Square Tests and Fisher Exact Tests to determine statistical significance at a 95% confidence level. This rigorous methodology allowed for a detailed examination of medication error patterns and potential differences between HCAs and other nursing staff in Alberta LTC facilities.
Results: Analyzing Medication Error Data from Alberta LTC Sites
The survey component of the broader study revealed that a small percentage, specifically 5% (three out of 64), of long-term care (LTC) sites in Alberta reported involving health care aides (HCAs) in oral medication assistance. For the purpose of this error rate analysis, medication error reports were obtained from two of these facilities, designated as Facility A and Facility B. Both facilities were publicly owned. Facility A had 44 LTC beds, while Facility B was larger, with 120 LTC beds. In terms of staffing, Facility A employed 31 HCAs, four Registered Nurses (RNs), two Licensed Practical Nurses (LPNs), and one care manager. Facility B had 76 HCAs, seven RNs, nine LPNs, and two care managers. Notably, mandatory medication assistance training, aligned with Alberta Health and Wellness guidelines, was in place for HCAs at both facilities.
At both Facility A and Facility B, HCAs were involved in assisting with both oral and topical medications. All medication administrations and non-administrations were meticulously documented in medication administration records. The types of medication assistance provided by HCAs at these facilities included: (a) basic medications (non-medicated eye, ear, nasal, cream/ointment preparations, suppositories, and fleet enemas) as assigned by regulated providers, and (b) multi-dose medication package delivery (delivery of regularly scheduled oral medications in multi-dose packages to stable residents).
A comparison of resident health status between the LTC facilities involving HCAs in oral medication assistance and the control facilities (where HCAs were not involved) indicated that residents in the HCA-involved facilities presented with more complex health profiles in certain aspects. For instance, the average age and the proportion of residents diagnosed with depression were higher in facilities utilizing HCAs for oral medication assistance.
Analyzing the medication error data, approximately 50% of medication assistance at Facility A and 70% at Facility B were provided by HCAs. The calculated monthly incidence rate of medication errors was 2.6 per 10,000 medicines administered. Breaking this down by provider type, the error rate for HCAs was 2.4 per 10,000, slightly lower than the 3.1 per 10,000 rate for other healthcare providers (LPNs/RNs).
Across the two facilities, a total of 220 medication errors were reported by all healthcare providers, including HCAs. HCAs were involved in the majority of these errors, accounting for 137 (63%), while LPNs/RNs were involved in 77 (35%), and pharmacy in 4 (2%). The error data spanned approximately two years, from October 2012 to January 2014. The most frequent type of error was dose omission (61%, n = 134), followed by wrong resident errors (8.6%, n = 19) and incorrect drug errors (7%, n = 15).
Regarding error severity, no “high severity” errors were reported during the study period. The majority of errors were classified as “minimal severity” (53%, n = 117) or “no apparent harm” (43%, n = 95). “Moderate severity” errors constituted a smaller proportion (4%, n = 8). The incidence rate of “moderate severity” errors among all errors was 3.6% (95% CI = [1.7%, 6.8%]). Crucially, statistical analysis revealed that HCAs were significantly less likely to cause “moderate severity” errors compared to other healthcare providers (2% vs. 7%, chi-square = 5.1, p value = .04). This suggests that while HCAs are involved in a majority of reported errors by volume, the severity of these errors tends to be lower compared to errors made by other nursing staff.
Discussion: Implications for HCA Medication Assistance in Alberta LTC
This study’s analysis of medication error reports from two Alberta long-term care (LTC) facilities provides valuable insights into the safety of involving health care aides (HCAs) in oral medication assistance. The findings suggest that, under appropriate guidelines and conditions, HCAs can be safely integrated into oral medication assistance in LTC settings. These findings are particularly relevant to the ongoing development and refinement of programs like the “alberta provincial continuing care medication assistance program,” and highlight the importance of clear operational frameworks, potentially outlined in resources akin to an “alberta provincial continuing care medication assistance program map manual.”
The observed lower rate of moderate severity errors by HCAs compared to other nursing staff is a key finding. This contradicts initial concerns about increased risk associated with HCA involvement in medication assistance. Several factors could contribute to this outcome. Firstly, the facilities in the study implemented automated medication packaging, a system known to reduce medication errors. Secondly, HCAs in these facilities were trained according to Alberta Health and Wellness guidelines, emphasizing safe medication assistance practices. Thirdly, HCAs typically assist with less high-risk medications, excluding insulin and narcotics, which are associated with more severe consequences if errors occur. It’s also plausible that HCAs, recognizing their role, may exercise greater diligence and caution in medication assistance, leading to fewer severe errors.
The study identified dose omissions as the most common error type, consistent with findings from other research in continuing care settings. While HCAs were involved in a higher proportion of overall errors, standardizing error rates by the proportion of medications assisted by each provider group indicated that HCAs had a slightly lower error rate than other nursing staff. This further supports the conclusion that HCA involvement in oral medication assistance, when properly managed, does not necessarily increase medication error rates.
The comparison of resident characteristics revealed that facilities utilizing HCAs in oral medication assistance cared for residents with more complex health needs in some areas, such as higher average age and prevalence of depression. This suggests that the lower severity of errors by HCAs is not simply attributable to them caring for a less complex patient population.
However, it is crucial to acknowledge the study’s limitations. The reliance on self-reported medication error data introduces the possibility of underreporting. The study also only included two facilities, limiting generalizability. Furthermore, there’s a potential for HCAs to have less experience in recognizing and reporting medication errors compared to nurses.
Despite these limitations, this research provides a foundation for future investigations. Future studies should explore strategies to optimize HCA involvement in oral medication assistance processes in LTC. Gathering perspectives from residents and their families on HCA involvement is also essential. Addressing potential workload implications for HCAs is important to ensure that expanded roles do not compromise overall resident care. Facilities considering involving HCAs in medication assistance should carefully evaluate staffing levels and ensure adequate HCA training and ongoing supervision by regulated healthcare professionals, potentially guided by resources like an “alberta provincial continuing care medication assistance program manual” if available.
Conclusion: Safe Integration of HCAs in Alberta Medication Assistance Programs
The findings of this study suggest that health care aides (HCAs) can safely contribute to oral medication assistance in long-term care (LTC) settings in Alberta, provided they operate under established guidelines and receive appropriate training and supervision. This research supports the potential for increased HCA involvement in medication assistance as a means to achieve cost-effective and efficient workforce utilization within continuing care facilities. Further research on a larger scale is warranted to definitively assess the impact of HCA involvement on resident safety and to comprehensively evaluate the cost-effectiveness of this model of care. Future investigations should also consider the practical resources, like an “alberta provincial continuing care medication assistance program map manual,” that could support the safe and effective implementation of HCA-led medication assistance programs across Alberta’s continuing care system.
Acknowledgments
The authors gratefully acknowledge the members of the advisory committee for their valuable advice and feedback throughout this project. We also extend our appreciation to Julia Bicknell for her editorial support in preparing this manuscript.
Appendix
Appendix. Definitions of the Severity of Errors.
| Hazard | A hazard or hazardous situation that has been identified as having the potential to escalate to a close call or a harmful event. This hazard exists as a latent condition. For example, a piece of equipment may be difficult to use; the staff may feel that it is potentially error prone. Another example is two similar looking drugs located side by side in a container. |
|---|---|
| Close call | An event or circumstance that has the potential to cause a harmful event but did not actually occur due to corrective action and/or timely intervention. The event did NOT reach the patient. An example is pouring the wrong medication and having taken it to the bedside; the mistake is caught on the last check before giving it to the patient. An inappropriate dosage of a medication is detected before an order is processed. A nurse discovers a patient is allergic to penicillin when checking the name band before hanging the IV penicillin dose. A physician is reading the wrong CT results for the patient that is being examined but notices that the report is not making sense and requests the correct report. |
| No apparent harm | An event or circumstance where at the time of the event or reporting of the event the patient does not appear to suffer any harm but could do so in the future. No physical and/or psychological symptoms are evident and no intervention is required. For example, a patient falls and hits his or her head but no evidence is found of bruising, swelling, or any change in neurological status or cognitive function. A patient received a wrong medication but exhibited no change in symptoms or condition as a result. |
| Minimal harm | An event or circumstance where there is minimal harm to the patient. Minimal adverse effects may include abrasions, skin breakdown, pain, minor burns, bruises, scratches, confusion, emotional distress, and anxiety. These effects may or may not require intervention. Intervention for minimal harm may include x-rays, sutures, physician examination, blood collection, or re-collection and closer observation, even if short-term in nature. For example, a patient received a dose of insulin that was higher than expected; a new order was received and extra food was given to reduce blood glucose levels with a follow-up glucometer check. A patient falls, sustains a bruised and swollen knee, and requires some Tylenol and an ice bag for a few hours but this does not extend the stay in hospital. Extra observation and monitoring may be needed such as an increase in vital signs frequency for the next 4 hr but no overall changes in the treatment plan would be required. |
| Moderate harm | An event or circumstance where there is moderate harm to the patient. Moderate adverse effects may include moderate lacerations, fractures of the extremities, burns, and unintentional heavy sedation. Intervention and extended observation are required. Intervention for moderate harm may include diagnostic testing such as MRI, CT scans with contrast, blood gas analysis, or cross-match for blood products. An event or circumstance causing moderate harm has the potential to prolong length of stay. For example, a patient falls, sustains a fractured arm that is cast, and function recovers through a short period of physiotherapy. A patient is found to have retained a sponge in abdominal surgery, develops an internal infection, and requires a repeat procedure to retrieve the sponge and a 10-day course of antibiotics. A change occurs in the treatment plan to deal with the new symptoms or condition arising from the adverse event. |
| Severe harm | An event or circumstance where there is severe harm to the patient. Severe adverse effects may include anaphylaxis, permanent injury or disfigurement, fractures (other than extremities), or a sudden life-threatening change in vital signs. Immediate, life-saving intervention is required and may include life support and/or an emergency surgical occurrence. For example, during a surgical procedure, the wrong part is inadvertently removed. A patient receives a contrast dye to which he or she had a known allergy and suffers a cardiac arrest. A wrong dose of a medication leads to a loss of hearing. |
| Death | An event or circumstance causing death in which the most likely cause is due to an error that occurred in the course of receiving care. Note that multiple deaths should be entered in separate reporting and learning submissions. |
Note. IV = intravenous; CT = computed tomography; MRI = magnetic resonance imaging.
Footnotes
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Alberta Health (Grant 003760).
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