One of the problems with the homes is that pharmacists are hardly ever told when a drug has been stopped or changed, which could contribute to the medications errors mentioned. I checked a prescription for a patient prescribed co-amilofruse 10/80: 1 tab od on 1 prescription and furosemide tab 40mg: 2 tabs bd on a different prescription dated a week before.

My dispenser had to speak to 3 different receptionists before we could get an answer : she read from the notes that the patient was hospitalised and amiloride was stopped then. Obviously, they didn't think about telling us about the change. And no doctor was around to talk to us...The hospital will communicate with the GP but pharmacists are left off the loop.

As a locum working for some of the big multiples it is quite astounding to see the non0 compliance to assembly of blisters. Surely if you have room for info printed on these blisters, this is info regarded as necessary for accuracy in both dispensing and checking. I refer to identification information for medicines ie colour, shape, markings etc. there seems to be a total disregard for these by dispensers/ their tutors/managers, You try checking a blister with 6 smallish white tablets all in morning, with not even a sample tablet at your disposal!! Some times not even the stock containers are left with the blister. Labels are also just duplicated from scripts and not specific as to morning, evening etc-just one daily. Checking these typse of blisters is VERY timeconsuming and stressful. There are SOP's in place for all other processes and beware if you don't comply, but SOP's for blistering don't seem to be as important-it's dispensing ,isn't it.

People don't seem too suprised by this news, but 37% sounds rather high to me. It would be interesting to know more of the details of this study. I would also challenge any pharmacist working in the appalling work conditions described to cause a serious stink.

Working in a very busy MDS room myself I cannot say I am surprised. A certain multiple seems to expect twice as much work from its dispensing staff without increasing staffing levels- for example the other week I had an ACT start checking a home I was dispensing, before I had finished the last patient, as the drivers were waiting and becoming impatient, as their workload is barely managable!
Everyone is costantly stressed and mistakes unfortunately do happen. I'm not condoning them, but think getting the staffing levels right in both the Care Homes and the Pharmacies would be a good place to start.

In certain multiples i have done locums in, the checking of MDS prescriptions is done entirely by Accuracy checking technicians with the pharmacist being asked to do 'clinical checks' only. This means the pharmacist hasnt got a clue what tablet actually gets to the patient. 'Great use of resources in pharmacy'!? Really!? I wonder how many patients get the wrong drug, wrong strength, drug with similar name (penicillin vs penicillamine)' drug with same colour packaging? One MDS ROOM i went to was an 'open office' type room where 4 dispeners and 2 ACTs are popping pills into dosset boxes while chatting about Coronation street and some music blasting away in the background! I thought,'great environment for ACCURATE checking!'

i suspect a proper study (larger sample) of medicines use in care homes might reveal some horror stories!?

My father ,also a Pharmacist had similar experiences 40 yrs.ago so nothong's changed. After 1 months hospital locum work recently I decided to retire early. A verication Pharmacist initiates action for each script.Then there are 3 technicians before I checked. I need to verify myself! Yes someone else should check me as concentration is often disturbed whilst trying to listen to everything else which is going on in a busy pharmacy. In comm. pharm. preparing MDS's I found that I was spending a huge ammount of time talking to Dr's and caring staff over and over again about doses,forms,side effects,administration times. IIt would be great if Dr's had Pharmacists with them on Care Home rounds to ensure prevention of many time consuming discrepancies. Jenny Meade

I'm not surprised. Although not a care home, I was in hospital twice over the past 2 years, and on both occasions, had I not been a pharmacist and realised, I would have been given the wrong dose several times - by trained and qualified nurses. A sub dose of Buscopan, and an over dose of paracetamol. Also, an i/v antifungal I was being treated with was left unrefrigerated. The error was picked up, but nothing was done about it in terms of reporting the issue to prevent the same happening, until I happened to mention it to the nurse in charge!