Older adults receiving home care often face significant safety risks related to medication management due to their chronic diseases and complex health needs. Despite the increasing reliance on home healthcare services, the specific factors contributing to medication safety risks in this demographic remain inadequately explored.
Objective/Aim
This study aims to explore the key factors involved in medication safety risks among older adults with chronic diseases receiving home healthcare in Iran.
Methods
Qualitative research employing conventional content analysis was conducted using Graneheim and Lundman’s approach. was conducted in three home care centers in Tehran (Iran) from August 2020 to July 2022. Data were collected through semi-structured interviews with 7 nurses, 2 supervisors, 2 nursing assistants (experts in non-nursing careers), 1 home care inspector (expert of the Deputy of Treatment), and 3 family caregivers in home settings, along with four participatory observations and visual methods (narrative photography) focusing on medication safety challenges. The trustworthiness of the research was evaluated using Lincoln and Guba’s four criteria for qualitative studies.
Findings
Factors associated with medication safety risks were found to rely on its major components Patients’ attribution, Families’ characteristics, Home care centers’ condition, Health caregivers’ characteristics, and the Homes’ situations, where these factors all account for various medication safety risks. Indeed, a medication safety risk can be attributed to more than one of the factors associated with medication safety risk by participants at home.
Conclusion
As a result, the analysis of factors associated with medication safety risks highlights a complex interplay among various elements, including patients, families, home care centers, health caregivers, and the home environment. These interconnected factors are crucial for identifying the diverse medication safety challenges faced by participants in home settings. A comprehensive understanding of these dynamics is essential for improving medication safety protocols and enhancing health outcomes for this vulnerable population.
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Introduction
Aging is a global phenomenon that poses significant challenges for health policymakers, particularly concerning older adults with multiple chronic conditions who often receive care at home [1]. As the population ages, there is an increasing emphasis on delivering effective and safe healthcare services to this vulnerable group [2]. Home-based care has emerged as a primary option within healthcare systems due to its cost-effectiveness and potential to enhance patient satisfaction and quality of life [1, 3]. In Iran, home care services are provided through specialized centers that employ healthcare professionals, including nurses and nursing assistants, to address the diverse needs of patients [4, 5]. Home care centers operate under the supervision of universities of medical sciences and the Ministry of Health and Medical Education(MOHME) [6]. Unlike many Western countries, where home care is often integrated into broader healthcare systems with standardized protocols, Iran’s home care system operates under distinct cultural and operational frameworks [5]. These differences include varying levels of caregiver training, family involvement in care processes, and regulatory oversight by local health authorities. The unique context of Iran’s home care system may contribute to specific medication safety risks that differ from those observed in other countries [4, 5]. For instance, the reliance on family members for medication management, combined with varying degrees of caregiver competence and inconsistent communication among healthcare providers, can exacerbate the potential for medication errors [7]. Furthermore, the lack of standardized procedures for medication reconciliation and oversight in home settings raises additional concerns regarding patient safety [7, 8]. Despite the advantages of home healthcare, significant threats remain, particularly related to medication safety [9]. Aging populations, particularly older adults with chronic diseases, face significant medication safety risks in home healthcare settings [7]. Home Healthcare Medication Safety Risks refer to the potential for medication errors and adverse drug events that can occur when medications are managed outside of traditional healthcare facilities [8]. Medication errors—such as incorrect dosages or improper administration—are prevalent issues that can lead to adverse health outcomes for older adults [8]. Medication safety risks are ranked 4th to 6th cause of mortality in the United United States [10]. Overall, adults aged over 65 with chronic diseases are at elevated risk for medication-related problems [7]. Importantly, these patients are at higher risk due to the polypharmacy phenomenon, cognitive impairments, and environmental hazards typical in home settings [6].
Research indicates that these safety risks are heightened in home environments due to factors such as environmental hazards and insufficient caregiver training [5, 11]. While existing literature has documented various aspects of medication safety risks in home care settings globally, there is a notable lack of focused studies examining these risks from the perspectives of participants within Iran’s unique healthcare landscape. This study aims to explore the key factors involved in medication safety risks among older adults with chronic diseases receiving home healthcare in Iran. By understanding these critical components, we can develop targeted interventions that enhance medication safety protocols and ultimately improve health outcomes for this vulnerable population.
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Methods
Study design and setting
This study was conducted with qualitative research and conventional content analysis. Conventional content analysis is a qualitative research method that focuses on understanding the context and meaning of textual data, allowing researchers to identify patterns and themes without preconceived categories. This approach is particularly effective in exploratory studies, such as examining medication safety risks among older adults with chronic diseases. It enables an in-depth exploration of participants’ experiences and perspectives, facilitating the extraction of nuanced insights from interviews with healthcare providers and family caregivers. In this approach, we utilized three methods of data collection: interviews, observation, and narrative photos. The study was conducted following Graneheim and Lundman’s approach [12] and reported by the Consolidated Criteria for Reporting Qualitative Research (COREQ) [13] (Supplementary file 1).
This study was conducted in three home care centers located in Tehran, Iran, from August 2020 to July 2022. The selected centers provide comprehensive home healthcare services for older adults with chronic diseases, employing a range of healthcare professionals including nurses, nursing assistants, and non-professional caregivers. These centers operate under the supervision of universities of medical sciences and the Ministry of Health and Medical Education (MOHME), ensuring that care is aligned with national health policies. The home care system in Iran is characterized by its reliance on both formal caregivers and family members who play a critical role in managing medication safety.
Sampling
Participants in this study were selected through purposive sampling from August 2020 to July 2022 to ensure maximum variation among home care nurses, other home health care providers, and family caregivers with experience caring for older adults with chronic diseases. The selection aimed to include individuals who were not only experienced in home health care but also enthusiastic about participating in the study. By interviewing individuals with diverse backgrounds in terms of age, gender, marital status, education level, and home care experience, we achieved the desired variation.
The inclusion criteria for this study required that nurses and nursing assistants have a minimum of one year of work experience in home care, while family caregivers needed at least one month of experience caring for a patient at home. Exclusion criteria included the termination of collaboration with the home care center for nurses and healthcare providers and the death of older adults with chronic diseases for family caregivers. Importantly, no participants refused to participate or dropped out of the study.
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Once the inclusion criteria were applied and the research objectives were established, suitable times and locations for the interviews were scheduled.
Data collection
Data were collected through semi-structured (face-to-face) interviews, participatory observations of home care, field notes, and analysis of home care photos. To begin, we contacted the participants after obtaining permission from the officials of the home care centers. After explaining the process and choosing the participants based on the inclusion criteria and explaining the research objectives, the place of interviewing was chosen to be at the home care center or the patients’ homes on the participants’ preference.
The first author conducted 60-to-90 min in-depth and semi-structured interviews with the participants about their experiences. Each interview started with an open question and then continued with probing questions to achieve the research objective. The participant was allowed to reply to questions easily and freely to minimize the impact on their opinions. The participants were asked, for example, to mention factors contributing to and/or threatening the patient’s medication safety at home, based on their experiences. Some questions asked in the interviews included: “In your experience, what factors contribute to medication safety for patients at home?” and “Based on your experience, what factors and challenges pose a threat to medication safety for patients at home?“, “What have you done to reduce these medication safety risks?” ?“, “What action did you take when your patient was in danger?“, “Can you tell me more?”(The interview guide is attached in supplementary file 2.). Probing questions were employed based on the responses of the participants, along with clarifying questions during the interview, to ensure the research objectives were addressed. Finally, the interviewee was invited to identify any additional factors that might aid the study process. All the interviews were ended by asking the participants about any question or point that they wanted to discuss. Upon the informed consent of the participants, all interviews were recorded by a voice recorder and then transcribed verbatim. Data were managed in Comment software. No new data were obtained from Participant 12 onward, and it seemed that all concepts were adequately addressed. However, three additional interviews were conducted to warrant full data coverage, with the obtained data included in appropriate categories. Throughout this process, we observed that the data became repetitive, with no new themes or insights arising in subsequent analyses, further supporting our determination of data saturation.Furthermore, four separates by the researcher (S.K) “observer as participant” sessions were conducted (mean duration in hours: 11.35 ± 5.23) for 8 to 11 h (one shift about seven hours or more) to check how maintaining and prescribing drugs and recording medication reports, and examine the quality of interactions between participants in the homes of older adults with chronic diseases. To encourage participants, observations were as “observer as participant” [14] where the observer performed some care activities, such as teaching the patient and family. During the observations, the researcher tried to ask questions to the participants whenever necessary during the interview ) and noted the response(s) [15]. It should be noted that the participants in the observations were different from the participants in the interviews. During observations, field notes were recorded as a supplementary method to collect data and fill the gaps in the categorized data, to confirm and assess the situations where at-home medication safety risks happen. Similar to observations, field notes were then coded and analyzed. During the observations, visual methods (photo narration) were used to access the experiences and voices of the participants [16, 17]. Ultimately, the photos were taken by the first author with a digital camera to analyze the conditions of medication maintenance and prescription, and record drug reports in the homes of older adult patients with chronic diseases.
Data analysis
In this study, data were collected and analyzed concurrently through five steps of the conventional content analysis using Graneheim and Lundman’s approach (2004), including a word-to-word transcript of each interview, observation and narrative photos, multiple readings of the interview, observation and narrative photos transcript for deep understanding, coding of semantic units, categorizing primary codes, and identifying hidden content in the data [12]. Interviews, observations, field notes, and narrative photos were immediately transcribed. Similarly, the narrative photos were interpreted and then written as transcripts according to the research’s objectives and medication risks threatening the patient’s safety [17].
All texts of interviews, observations, field notes, and narrative photos were read and reviewed several times by the researchers to ensure full data coverage. Words, sentences, and paragraphs related to the research’s objectives were considered as semantic units. The semantic units were coded according to the participants’ words or appropriate labels extracted from the data. All the codes were regularly reviewed, analyzed, and compared. Similar codes (with similar concepts) were grouped into similar categories, the main categories were created, and the main categories of factors associated with medication safety in home care patients were created. The research methodology and analysis process are summarized in Fig. 1.
Fig. 1
Research methodology (conventional content analysis) and analysis process
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Trustworthiness
The research trustworthiness was assessed using four Lincoln and Guba’s Evaluative Criteria (1985) for measuring the rigor of qualitative studies [18]. The credibility was confirmed by a long-term engagement with the data for two years (the result of a Ph.D. thesis), observations, interviews, and narrative digital photos to collect data (triangulation), and the member control method (to control categorizes inferred by participants). The confirmability and dependability were confirmed by recording audio and text interviews, notes, memories, codes, categorizes, photos, and observations in a safe place with confidentiality, oversight of all stages of the work by the supervisor and consultant, and using auditing techniques with the help of two external referees (qualitative research experts). The transferability was achieved by full observation and description of the home care context during different stages. Data authenticity was confirmed by self-awareness about the preconceptions and assumptions on factors associated with medication safety of older patients with chronic diseases in home care, while avoiding biases.
Ethical consideration
This study was conducted with ethical approval (code IR.IUMS.FMD.REC1399.430) from Iran University of Medical Sciences (IUMS), Tehran. Participants, including family caregivers, nurses, supervisors, and patients (if cognitively able), were informed about the research objectives and provided consent before participating in interviews, observations, or photography. They were assured of the confidentiality of their information and that their faces would not be shown in the photos. Any images deemed inappropriate by participants were deleted. For their safety, researchers provided tips to help avoid potential medication safety risks during the study. t.
Findings
Fifteen interviews were conducted (By the first author: S.K) with 7 nurses (P11-P5, P7, P10), 2 supervisors (P6, P8), 2 nursing assistants (experts in non-nursing careers) (P11, P12), 1 home care inspector (expert of the Deputy of Treatment) (P9), and 3 family caregivers(P13-P15) in three home care centers affiliated with the Tehran University of Medical Sciences (TUMS, Tehran). The health caregivers (females: 50%; males: 50%) attending this study had a mean “age” and “work experience” of “37.83 ± 4.23” and “7.75 ± 1.23” years, respectively. Of all family caregivers, two were females and one was male. The mean “age” and “Participation in care” of family caregivers were “38.33 ± 8.56” and “1.43 ± 0.23” years, respectively.
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In this study, the homes of care-receiving patients were observed four times, where there were four nurses (mean “age” and “work experience”: 40.25 ± 7.26 and 12.35 ± 3.2 years), four older adult patients with chronic diseases (mean age: 78.25 ± 12.65 years), and four family caregivers (mean “age” and “work experience”: 47.75 ± 9.85 and 1.45 ± 0.54 years). Furthermore, 12 photos of medication safety hazards were taken to be analyzed through visual observations.
The findings in this research are classified into 5 Categories, and 27 sub-categories (Table 1). It was found that factors associated with medication safety risks rely on the main contributors (i.e., the patient, family, home care center, and health caregiver) and the home environment, all collectively accounting for medication safety risks (Fig. 2).
Table 1
Main categories, sub-categories
Main categories
Sub- categories
Primary codes
Patients’ attribution in Their Own Safety
Polypharmacy
Multiple medication uses and increased risk of drug interactions
Long-term medication uses for chronic conditions
Old age and chronicity
Increased prevalence of chronic diseases with aging
Aging and its negative impact on organ structure and function
Overuse of painkillers
Chronic pain and inappropriate management
Creating dependency and addiction to painkillers
Physical side effects, such as liver and kidney damage, due to excessive use of painkillers
Patient’s cooperation
Stubbornness toward nurses, risking self-harm
Patient’s disregard for nurses’ recommendations regarding timing, storage, and drug interactions
Families’ characteristics and Their dynamic Role
Lack of knowledge
Family’s lack of awareness about the patient’s needs
Family’s lack of knowledge about proper medication storage
Insufficient knowledge about drug interaction side effects
Improper interventions
Performing unsafe medication actions
Insisting on implementing unsafe medication procedures
Unsafe interventions
Inadequate financing (pharmaceutical and non-pharmaceutical)
Incomplete medication procurement by family due to financial issues
Lack of financial support for medication consultation
Failure to provide necessary supplies and equipment
Excessive sympathy
Excessive pity and insistence on giving pain medication to the patient
Compassion and disregard for nurse’s warnings
Lack of cooperation
Lack of involvement in caregiving
Abandonment of safe care procedures
Ineffective communication
Arguments and disputes over implementing safe measures
Mutual distrust
Homes’ situations : Living environment, not a care facility
Indiscipline at home
Disorganized medication boxes and potential for medication errors
Disorder in medication storage at home
Mixing injectable and oral medications
Storing all medications together
Inappropriate space for care
Small living spaces prevent the separation of drugs and equipment
Lack of a separate cabinet for organized drug storage
Limited supply
Absence of medication organizers at home
Insufficient medication access
Inadequate access to appropriate equipment
Co-presence of more than one patient or old patient at the home
Numerous medications and equipment, increasing the risks of interactions, especially for elderly couples
Mixing medications of elderly individuals with multiple illnesses at home
Home care centers’ condition to maintaining Safe Medication Management
Poor management: supply and distribution
Poor management of medication supply for home care
Insufficient supervision and delayed medication delivery
Inadequate follow-up for medication procurement and distribution at home
Insufficient follow-up and supervision of correct medication instructions
lack of supervision
Inadequate monitoring of drug interaction occurrences
Insufficient supervision of documenting medication usage
Inadequate supervision of safe medication storage at home
Shortage of training in drug interactions
Lack of training
Absence of home medication safety training
Absence of home medication safety training
Lack of comprehensive laws for ensuring medication safety at home
Unidentified rules and policies
Absence of clear guidelines for addressing medication errors at home
Lack of protocols for reviewing medication errors and interactions at home
Lack of an inclusive electronic system for in-home care recording medications
Lack of an inclusive electronic system
Use of outdated Kardex systems, leading to high medication error risks
No medication consultation requests by specialists
Limited periodical pharmacology consultations
Neglecting periodic review of medication instructions
Lack of clear guidelines for periodic medication and interaction review
Inadequate medication-related skills among home care nurses
Health caregivers’ characteristics and Challenges to sustain adequate Safe Medication care
Lack of competency: patient-oriented care
Limited drug knowledge among home care nurses
Insufficient attitudes toward medication safety among home care nurses
Fatigue during long shifts
A long shift
The high number of shifts
Fear of judgment upon disclosure
Fear of error disclosure
Fear of impact on salary and benefits upon disclosure
Fear of exclusion upon disclosure
Lack of a culture for addressing medication errors
Lack of implementation of finding roots of errors
Insufficient knowledge of handling medication errors
Underestimating the importance of addressing medication errors
Neglect by nurses in reviewing medication errors
Lack of monitoring and evaluation of side effects and drug interactions
Nurse’s inattention to reviewing medication side effects in elderly patients
Nurse’s inattention to reviewing appropriate medication response
Disorganized medication boxes and potential for medication errors
Fig. 2
Medication safety risks in-home care
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Factors associated with home healthcare medication safety risks among the older adults with chronic disease:
1.
Patients’ attribution in Their Own Safety:
Participants believe that Patients’ attribution (as a recipient of home care services) can affect the occurrence of medication safety risks. Such impact can be intentional (i.e., calling for overuse of painkillers and patient cooperation) or unintentional (polypharmacy, old age, and chronicity). The patient’s calling for the overuse of painkillers regardless of the physician’s instruction and advice of health caregivers appears to be a major medication safety concern. Such a need for painkillers is particularly seen in old patients and/or those with chronic diseases due to their medical condition. However, the participants think that prolonged use of these drugs results in a psychological dependency on using more painkillers, which threatens the safety of patients at home. Patient’s poor cooperation with the health caregivers and irregular use of medicines are other causes threatening the patient’s safety at home. The parallel use of multiple drugs (polypharmacy), chronicity of diseases, and oldness all increase the risk of medication safety risks, drug interactions, and drug overuse.
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According to a female nurse with 20 years of work experience(P1):
“My at-home patients are often aged 60 to 70 years or suffer from co-existing diseases, thereby taking more than three or four types of medications; there may be at least one drug that interacts with others”.
The next female nurse with 7 years of experience declares that(P4):
“I had a highly ill-tempered and stubborn patient, calling, for example, two shots of painkillers at night (for more convenient sleeping) instead of the one shot recommended by the physician. Often, she threatened me to listen and obey what she says and refused any suggestion of mine”.
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2.
Families’ characteristics and Their dynamic Role:
According to the participants, the family, as a patient’s care component, plays a pivotal role in medication safety (Preparation and storage of pharmaceutical and non-pharmaceutical), and it accounts for drug supply and costs and related affairs (i.e., financing by itself or entrusting it to the home care center). The family’s failure to finance and supply medications and related items for any reason can threaten medication safety. In addition, families with a lack of knowledge in-home care, especially in the first days of a patient’s arrival at home, threaten medication safety. Excessive family sympathy and lack of cooperation with health caregivers may be unsafe for the patient. The family’s failure to report side effects of drug interactions or poisoning due to ineffective communication was another factor that affected medication safety.
According to a female nurse supervisor with 20 years of work experience(P8):
“We had a family that was lately preparing medications, causing interruption prescribing antibiotics, so we had to regularly change the medications. This may be due to the family’s unawareness of the importance of on-time drug dispensing”.
According to a female patient’s spouse with three years of experience in home care(P14):
“I’m highly sympathetic; she requires painkillers for her pain and I can’t see my wife suffering. Sometimes, I stealthily give her Oxycodone, regardless of what the nurse and doctor say”.
A female nurse with 20 years of experience says that(P1):
“The family must help and be involved in the therapy; for example, by saying that the recently prescribed medication has some side effects, or makes the patient sleepy, or something else. I continually ask them, as they can let me know more about the therapy progress”.
3.
Homes’ situations: living environment, not a care facility:
According to the participants and observations, irregularities at home (e.g., storing medications in cupboards designed for domestic uses) and the home space not appropriate for storing and dispensing medications cause risks to the safety of drugs at home. As stated by the participants, some drugs are difficult to keep at home due to barriers to providing optimum temperature – for example, storing drugs like insulin in the food refrigerator at the wrong temperature. Furthermore, some limitations for the sufficient supply of drugs or keeping vital drugs at home enhance the risks of medication safety. According to the participants, the presence of more than one older adult or chronically ill patient at home multiplies the chance of medication safety risks.
According to a female nursing assistant with 11 years of work experience(P11):
“Drugs are fairly difficult to arrange and sort, especially those frequently consumed ones. We have sometimes cabinets full of drugs and have limited space”.
When observing how medications are stored in the home of a patient with a chronic disease, “insulin was found to be kept in the refrigerator’s door adjacent to food materials, while there was no thermometer in the refrigerator for temperature measurement. To store food materials within the right temperature, the refrigerator’s temperature was constantly altered, thus violating the threshold temperature for the medications”.
Similarly, when observing the home of an older adults adults patient with chronic ALS, where the family’s daughter (taking care of her parents) and a nurse with 18 years of experience were serving at the home, it was found that:
“Besides the patient, their spouse was also suffering from diabetes, hypertension, and Alzheimer’s disease. At home, only one shelf of a cabinet has been dedicated to storing all the medications, and this has caused problems in sorting and finding the multitude of drugs”.
Figures 3 and 4a narrative photograph of how drugs were stored in the home of an older adult’s patient with a chronic disease. As can be seen (Fig. 3), “Due to the limited space and insufficient cupboards, a variety of drugs, sprays, vials, drops, and ointments are stored along with daily items such as Vaseline, test tubes, flexi tubes, wet wipes, plastic gloves, straw glue, bedsore protective pads, and used syringes”.
Fig. 3
A variety of drugs, sprays, vials, drops, and ointments are stored along with daily items such as Vaseline, test tubes, flexi tubes, wet wipes, plastic gloves, glues, bedsore protective pads, and used syringes
Fig. 4
Storing insulin vials and some drugs in the refrigerator’s door, adjacent to food materials
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According to narrative photography of the home of an older adults adults patient with diabetes and chronic CVA (Fig. 4):
“Insulin was found to be kept in the refrigerator’s door adjacent to food materials. There were other drugs stored in the refrigerator’s door”.
4.
Home care centers’ condition to maintaining safe Medication Management:
According to the participants and observations, the home care centers’ condition affects the medication safety of patients at home. Home care centers may threaten medication safety at home in ways such as wrong management when the patient arrives at home, wrong drug preparation and distribution, and limitations for preparing drugs. Based on participants, the care centers critically threaten medication safety due to insufficient training for health caregivers and a lack of supervision and rules and policies for medication control. This lack of proper training and established guidelines for medication management can lead to serious consequences for the participants. No having (and failure to design) an all-inclusive electronic system for home care because of internet limitations would threaten the medication safety of patients at home. According to the participants and observations, the lack of periodic pharmacological consultations by the home care centers can threaten medication safety.
According to a male nurse with five years of work experience(P7):
“We provide written instructions for drug use on the report sheet given by the center; the supervisor may also check it once or twice a week. no remote or electronic system exists to alert us of any potential medication error”.
According to the son of one patient(P13):
“As defined in the contract, the center shall buy drugs and supply them to us. Occasionally, I tell them to buy, for example, more antibiotics or a certain painkiller, but they always follow their defined instructions. One day, the center failed to find the antibiotic, and my patient received one or two doses of it with a delay”.
According to a male nurse with 10 years of work experience(P2):
“No law or instruction leads the use or on-time dispensing of drugs, and we have to be careful and consider professional ethics”.
A male nurse with 9 years of work experience says that(P5):
“We received no proper training on drugs and associated side effects. Honestly, we only received some initial training upon entering the center, mostly irrelevant to medications”.
Similarly, we observed the home of an older adults adults patient with chronic lung cancer supervised by a nurse with 8 years of experience(P3):
“No resuscitation bag or urgent kit was found at home, and when asking the supervisor, the answer was that: urgent drugs have expired and are currently being prepared by the center, and this regrettably will take some time”.
According to a male supervisor with 12 years of experience (P6):
“We have no pharmacological consultation at home, while it appears to be crucial, especially for the elderlies and patients overriding drugs”.
5.
Health caregivers’ characteristics and challenges to sustain adequate safe medication care health:
According to the participants and observations, some characteristics of health caregivers (e.g., Lack of competency: patient-centered care, or taking long shifts for higher income) result in medication safety risks.
lack of monitoring and evaluation of drug side effects, particularly in sensitive older adult patients with chronic diseases and polypharmacy, was found to elevate the risk of medication safety risks. Some participants acknowledged the fear of disclosing their mistakes and attributed this lack of implementation to finding the roots of errors. Some others have reported relying on the advice and support of their coworkers in hospital settings to address any concerns about potentially dangerous or incorrect drug prescriptions, as this kind of support system is not available to them when they are at home. According to the participants and observations, lack of evaluation of drug side effects and interactions, no post-dispensing follow-up (especially for narcotic drugs), reevaluation ignoring reevaluation ignoring reevaluation with co-workers, and not record the documents accurately and appropriately by the health caregivers that can threaten medication risks of the safety (Fig. 5).
Fig. 5
The drug cardex with no patient details, sensitivity, and allergy, the dosage of some drugs, and the starting date and method of prescribing many drugs. There are some strikethroughs in the cardex
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As stated by a male supervisor nurse with 12 years of experience(P6):
“Regrettably, some nurses or nursing assistants have insufficient knowledge about medications, or they poorly consider side effects of drugs”.
According to a female inspector of home care:
“When checking complaints set against the centers, we found the caregivers’ fear of early reporting the problem,thereby provoking it further. Or we saw the centers to fail organize RCA2meetings and this further intensifies the problems”.
A male nurse with two years of work experience reported that(P10):
“We work alone at home and are deprived of our co-workers at the hospital to ask them any question about the arisen problem”.
When observing an older adults adults patient with chronic ALS at home supervised by a nurse with 6 years of work experience, we saw that “the nurse caring for the patient with chronic respiratory failure prescribed the drug (narcotic painkiller) and then sat on the couch next to the patient’s bed without reconnecting the patient to the pulse oximetry device”.
As mentioned by a male nurse with 5 years of work experience(P7):
“There is no co-worker to help check the drugs, particularly for their names or dosage and we don’t even double-check medications with supervisors”.
During observation from the home of an older adult’s patient with chronic CVA:
“The nurse injected IV antibiotics into the patient’s serum and then quickly sat on the nearby chair to work with their phone, with no attention to monitor the patient’s status”.
Based on a narrative photograph of the home of an older adults adults patient with chronic ALS(figure):
“The drug cardex had no data on patient’s demographics, sensitivity, and/or allergy, the dosage of some drugs, and the starting date and method of administration for drugs, leading to medication safety risks. The form had also some strikethroughs, and some drugs were illegible and written by brand names”.
Discussion
This study explored the experiences of participants to measure medication safety risks in home care settings. All the members of a typical home care setting including the Patients’ attribution, Families’ characteristics, home care centers’ condition and health caregivers’ characteristics, and the homes’ situations all account for the occurrence of medication safety risks.
Patients (as the recipients of home care services) were a source of safety risks in-home care and were found to potentially threaten medication safety by rejecting cooperation and/or calling for improper services from health caregivers. In addition, old age and chronicity resulted in polypharmacy and drug interactions. This issue is further compounded by factors such as old age and chronicity, which often lead to polypharmacy and subsequent drug interactions. Research consistently indicates that polypharmacy, which is the concurrent use of multiple medications, is particularly prevalent in older adult patients with chronic diseases, thereby increasing the risk of multimorbidity and adverse drug events [7, 19] Moreover, a study titled “Living with a variety of vulnerabilities that impact the safe management and storage of medication” underscores the complex interplay between socio-economic factors and medication management in this demographic [20]. Older adults, often living in challenging home environments, may face limitations due to cognitive decline, physical impairments, or insufficient support, which can hinder their ability to manage medications safely [20]. Given these challenges, timely oversight and comprehensive assessment of pharmacotherapy in this vulnerable population are desperately needed. Implementing strategies to optimize therapy by addressing all drug-related issues—such as preventing drug interactions and enhancing medication management in home care settings—becomes imperative [19]. Collaboration between healthcare professionals, caregivers, and patients is essential to create a safer medication management environment [21]. This might include regular medication reviews, effective communication about treatment plans, and the involvement of multidisciplinary teams to ensure that all aspects of a patient’s health are considered in care planning. Ultimately, these efforts will contribute to improved health outcomes and enhanced safety for older adult patients receiving home care services.
The families’ characteristics were the next source that threatened medication safety. As a component of home care that serves the patient 24 h a day, the family potentially threatens medication safety. As reported in the literature, the family can interrupt the patient’s medication safety by not cooperating with other components of the home care team [5], having low-care training and knowledge [22], having extreme sympathy, and having low financing or equipment [23]. The dynamics within a family can vary greatly, and these variations can influence the overall effectiveness of medication management strategies. For instance, a family that is well-informed and engaged in the care process may enhance adherence to medication regimens. In contrast, those lacking knowledge may inadvertently compromise the patient’s health outcomes.
Reporting changes in the patient’s status to the health caregivers was the next source through which the family can cause medication safety risks. This aspect was associated with the family’s awareness of changes in the patient’s status, which is a new finding in the present study. Overall, due to the family’s pivotal contribution to medication safety, family education, and promotion can largely avoid medication safety risks [22]. Families who lack training or understanding might overlook critical signs of deterioration or improvement, leading to delayed interventions and potential medication errors. Overall, due to the family’s pivotal contribution to medication safety, family education and promotion can largely avoid medication safety risks.
Other studies have mentioned family participation in-home care with the following titles: “Educating caregivers to support older adults [24], Providing support and services for caregivers [24], and Family education about behavioral and symptoms management [21]. The home care nurse can teach the family and thereby mitigate the occurrence of some drug side effects. In addition to education, fostering open communication between families and healthcare providers is essential. This relationship can ensure that families feel empowered to ask questions and engage actively in their loved one’s care. The home care nurse can teach the family and thereby mitigate the occurrence of some drug side effects. Moreover, implementing regular family meetings or training sessions can facilitate knowledge sharing and allow families to express concerns or suggestions, ultimately creating a safer medication management environment. By investing in the family unit, we can significantly enhance the overall well-being of the patient and ensure medication safety.
The homes’ situations were the next source that threatened medication safety. As stated earlier, the home space is unsuitable for patient care and can cause multiple risks, such as medication safety. According to the literature, lack of space, unarranged home space, limited supply of some drugs, and inadequate space for taking care are factors threatening medication safety [7]. Health caregivers often aim to prepare a separate space for care at home [4], but the rate of medication safety risks remains high, mostly due to unarranged home spaces. The presence of more than one older adult with a chronic disease in a house is the next contributor to medication safety risks, which is the next new finding in the present study. In Iran, the home care setting allows for simultaneous caring of several patients at home and this enhances the risk of medication interactions and errors. These challenges are compounded by the lack of standardized protocols for managing medications in such environments. Thus, it becomes increasingly important to recognize the unique dynamics of home care and assess how they influence medication management.
Allocating a separate care space for each old patient with chronic disease (particularly, separate drug boxes or storage places) appears to mitigate the risk of medication safety risks. Thus, managing the house space is a critical step to maintaining medication safety. Having designated areas can help in organizing medications and reducing confusion during administration. Furthermore, collaboration between health professionals and family caregivers can play an essential role in ensuring that appropriate systems are in place. Thus, managing the house space is a critical step in maintaining medication safety [25]. Addressing this issue not only benefits the patients directly but also alleviates some of the burdens on caregivers, fostering a safer and more efficient home environment for health care delivery.
The home care center is the next component of home care and a pillar of management, supervision, and coordination in a home care setting, thereby playing a pivotal role in medication safety at home. Proper management within these centers is essential for ensuring that patients receive their medications accurately and on time. The complexity of medication regimens for many patients complicates this task, making oversight and diligent record-keeping even more critical. As reported by studies, poor or no drug management (either upon the patient’s arrival at home or during the follow-up of drug preparation and distribution) can threaten drug safety [8, 19]. For instance, a lack of clear communication among care team members can lead to medication errors, with potentially serious consequences for patients’ health. Research has further reported lawlessness, having no inclusive electronic system to record drugs administrated, and no or inadequate training for personnel to maintain medication safety as reasons for home care centers threatening medication safety threats [26]. Timely and enough training and working with electronic devices to minimize human errors appear to effectively diminish medication safety threats [26]. Other studies have mentioned this with the following titles: put systems of variable effectiveness in place to manage medications [20] and Lack of medication system [21].
Health caregivers (particularly, nurses) are the next component of medication safety care at home. The competency of health caregivers and adherence to instruction on drug administration critically affect medication safety. Their role is pivotal not only in administering medications correctly but also in educating patients and their families about the importance of adherence to prescribed regimens. In most studies, competence has been defined as a merge of knowledge, skills, and personal characteristics. This combination allows caregivers to navigate complex situations effectively, ensuring that patients receive the right care tailored to their specific needs. Thus, the competency of health caregivers is a critical factor when performing tasks such as the right dispensing of drugs [8]. They must also be adept at recognizing potential interactions and contraindications that could jeopardize a patient’s health. Disclosure of errors and finding their roots are other factors associated with medication safety. Accurately identifying and analyzing medication errors not only protects patients but also enhances the overall healthcare system. Importantly, health caregivers are legally and ethically liable for reporting medication errors but they may overlook it because of fear of punishment or blame [27]. Accurately identifying and analyzing medication errors not only protects patients but also enhances the overall healthcare system. This fear can create a culture of silence that ultimately compromises patient safety. Therefore, educating caregivers about the importance of transparency and open communication in error reporting is essential for fostering a safer healthcare environment. Critically, it is crucial to expand the culture of disclosing errors and finding their underpinning reasons to avoid any future incidents [28]. Encouraging regular training and workshops can empower health caregivers to feel more comfortable discussing their mistakes. Other studies have mentioned this with the following titles: poly-literacy (health, medication, and healthcare system literacy) [20] and Raising awareness [21], Learning tools and resources for nurses, older adults, and their families [21]. These initiatives can significantly contribute to improving medication safety by equipping caregivers with the knowledge and confidence needed to perform their roles effectively. In conclusion, promoting a culture of safety, alongside the continuous development of caregiver competencies, is essential for optimizing patient care in home settings.
Conclusion
Medication safety risks are mostly due to (and affected by) factors associated with home care components and thereby multiple interrelated aspects. These risks can include medication errors, adverse drug reactions, and inadequate patient education, which are frequently exacerbated in non-institutional settings. For these medication safety risks to be overcome, it is crucial to consider a variety of factors and assess how these factors are interrelated. It is essential not only to identify the root causes of these risks but also to understand the dynamics of how they interact in real-world scenarios. Importantly, fixing all these factors is difficult, but it is possible to modulate them by adopting proper and versatile solutions. According to the research findings, the nurses are suggested to provide courses on at-home drug safety and correct ways of drug prescription. Moreover, enhancing communication between healthcare providers and patients can significantly reduce the risk of misunderstandings related to medication usage. Similarly, supervisors are recommended to strictly control the dispensing of medication in-home care, which can be realized by designing checklists to assess safe at-home drug administration, particularly in older adult patients with chronic diseases. Constant and periodic training on drug prescription at home, along with reflecting on drug side effects and interactions, are other practical solutions. These initiatives can help build a safer home care environment, empowering patients and caregivers alike. Ultimately, the Iranian healthcare system is suggested to develop a digital medication tool to check and control medication safety risks, similar to those in other countries. By leveraging technology and continuous education, we can significantly enhance medication safety and optimize patient outcomes in home care settings. All these measures combined could lead to a well-coordinated approach that fosters a culture of safety, potentially leading to improved health outcomes for patients in their own homes. It is suggested that future research focus on quantitative methods to measure the prevalence of medication errors among elderly patients with chronic diseases. This could involve assessing prescribing errors and their impact on health outcomes. Additionally, investigating the effects of educational programs and social support for elderly patients and their caregivers on medication safety would provide valuable insights into improving practices and reducing risks associated with home medication management. These suggestions aim to expand knowledge in medication safety within home healthcare and contribute to enhancing the quality of care for elderly patients.
Limitations
The Covid-19 pandemic and social distancing restricted us from conducting interviews and observations. Likewise, the participants had to wear masks and this prevented us from seeing their full faces and finding their facial status. The need to follow ethics for not displaying the photos of participants was the next limitation, as it restricted us to only writing the errors of participants, instead of capturing photos of their real-time Medication safety risks.
Acknowledgements
This study was supported by the Iran University of Medical Sciences (IUMS, Tehran). We appreciate all the participants and those who contributed to this research.
Declarations
Ethics approval and consent to participate
The protocol of this study was approved by the ethical committee of Iran University of Medical Sciences, Tehran, Iran (code of ethics: IR.IUMS.FMD.REC1399.430). While explaining the study’s objectives to the participants, they were assured that their information was kept confidential, and the principle of confidentiality was observed in all stages of the study until the submission of the report. Also, before each interview or observation informed consent was obtained from all participants. Likewise, all the families, nurses, supervisors, and patients (if having no cognitive impairment and low consciousness) signed the informed consent before entering the home for observations and photography. We confirm that the manuscript has been read and approved by all named authors. We confirm that we have given due consideration to the protection of intellectual property associated with this work. In so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. We further confirm that any aspect of the work covered in this manuscript that has involved either experiment on humans has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. It is confirmed that all procedures are performed in accordance with the relevant instructions and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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