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Int J Pharm Pract. 2014 Dec;22(6):407-14. doi: 10.1111/ijpp.12091. Epub 2014 Jan 23.

Exploring factors that contribute to dose administration aid incidents and identifying quality improvement strategies: the views of pharmacy and nursing staff.

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  • 1Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Vic., Australia.



Dose administration aids (DAAs) organise medicines that have been repacked according to the day of the week and time of the day in which they must be taken. In Australia, DAAs are commonly prepared by pharmacy staff for residential aged care facility (RACF) medicine administration. Although the limited available literature indicates that DAA incidents of inaccurate or unsuitable medicine repacking do occur, there is a paucity of qualitative research identifying quality improvement strategies for this service.


This study aims to investigate the perceived contributing factors to DAA incidents and strategies for quality improvement in RACFs and pharmacies.


Health professional perceptions were drawn from three structured focus groups, including six pharmacists, five nurses, a pharmacy technician and a personal care worker. Participants were involved in the preparation, supply or use of DAAs at pharmacies or RACFs that were involved in a previous DAA audit. Transcripts were analysed using thematic analysis.


Four major themes were identified as contributing to DAA incidents, with quality improvement strategies aligned to those same four themes: communication, knowledge and awareness, medicine handling and attitude. Strategies included improving interprofessional communication and addressing the limitations associated with RACF medicine records; targeting medicine knowledge gaps and increasing awareness of DAA incidents; encouraging greater care when preparing and checking DAAs; and fostering a team mentality among members of the aged care team.


Recommendations include using current findings to develop multidisciplinary quality improvement initiatives to prevent DAA incidents and to improve the quality of this pharmacy medicine supply service.

© 2014 Royal Pharmaceutical Society.


community pharmacy; compliance aids; delivery of care; elderly; interprofessional issues

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