Care home errors linked to medicine delivery method

Asthma inhaler

A study across care homes in England has revealed that dosing mistakes are most likely to involve inhalers rather than tablets, capsules or liquid medicines, with inhalers being used incorrectly half of the time.

Dr David Alldred and colleagues are now calling for care home staff to receive better training in the use of medical inhalers so that residents with breathing disorders get the treatment that they need.

“Approximately one in 10 care home residents will have been prescribed an inhaler-based medicine for some sort of respiratory disorder, such as chronic obstructive pulmonary disease,” said Dr Alldred, lecturer in pharmacy at the University of Leeds. “If that condition is not treated correctly, their breathlessness will not be relieved and they may be at higher risk of developing a chest infection.”

The researchers looked at data on 233 residents living in 55 care homes. They found that the chance of a mistake being made was 30 times higher when staff had to administer an inhaler rather than help a resident take some tablets. Residents had a one in two chance of getting the right dose when they were helped to use an inhaler. Also, the chances of an error occurring was four times higher when liquid medicines were administered rather than tablets or capsules.

Many mistakes involving inhalers happened because staff forgot to shake the device. Dosing errors also happened when staff administered the wrong number of ‘inhalations’ or when residents failed to hold their breath, allowing the inhaled powder to escape out of their mouth.

“Medical inhalers are relatively complex devices and require a number of steps to be taken correctly in the right sequence. Even the simplest inhaler can be difficult to use correctly and this is particularly the case for older people. This is why care home staff need proper training and support in using these devices. If that training is not being offered then we would urge them to seek support from their community pharmacist or Primary Healthcare Trust,” Dr Alldred said.

The study was funded by the Patient Safety Research Programme of the Department of Health. It was carried out in collaboration with the London School of Hygiene and Tropical Medicine, London and the School of Pharmacy, University of London.

Full details of the findings are published in the journal BMJ Quality and Safety.

For further information:

Paula Gould, University of Leeds press office: Tel 0113 343 8059, email

Dr David Alldred is available for interview.

Notes to editors

1.  The paper, ‘The influence of formulation and medicine delivery system on medication administration errors in care homes for older people’, is available online in advance of publication in the journal BMJ Quality and Safety (doi 10.1136/bmjqs.2010.046318).

2. One of the UK’s largest medical, health and bioscience research bases, the University of Leeds delivers world leading research in medical engineering, cancer, cardiovascular studies, epidemiology, molecular genetics, musculoskeletal medicine, dentistry, psychology and applied health. Treatments and initiatives developed in Leeds are transforming the lives of people worldwide with conditions such as diabetes, HIV, tuberculosis and malaria.