Exploring Australian pharmacists' views toward reducing the risk of medicines‐related harm in aged care residents

Abstract Medicines‐related harm is common in older people living in residential aged care facilities (RACFs). Pharmacists offering services in the aged care sector may play a key role in reducing medicines‐related injury. This study aimed to explore Australian pharmacists' views toward reducing the risk of medicines‐related harm in older residents. Qualitative, semi‐structured interviews were conducted with 15 Pharmacists across Australia providing services (e.g., through the provision of medication reviews, supplying medications, or being an embedded pharmacist) to RACFs identified via convenience sampling. Data were analyzed by thematic analysis using an inductive approach. Medicines‐related harm was thought to occur due to polypharmacy, inappropriate medicines, anticholinergic activity, sedative load, and lack of reconciliation of medicines. Pharmacists reported that strong relationships, education of all stakeholders, and funding for pharmacists were facilitators in reducing medicines‐related harm. Pharmacists stated that renal impairment, frailty, staff non‐engagement, staff burnout, family pressure, and underfunding were barriers to reducing medicines‐related harm. Additionally, the participants suggested pharmacist education, experience, and mentoring improve aged care interactions. Pharmacists believed that the irrational use of medicines increases harm in aged care residents, and medicines‐specific (e.g., sedative load) and patient‐specific risk factors (e.g., renal impairment) are associated with injuries in residents. To reduce medicines‐related harm, the participants highlighted the need for increased funding for pharmacists, improving all stakeholders' awareness about medicines‐associated harms through education, and ensuring collaboration between healthcare professionals caring for older residents.


| INTRODUC TI ON
Medicines-related harm is any injury resulting from the use of medicines. 1,2 Advancing age is associated with an increased risk of medicines-related harm, such as falls, fractures, delirium, functional decline, cognitive impairment, hospitalization, and mortality. 3 The combination of factors such as old age, multiple comorbidities, and polypharmacy, increases the risk of medicinesrelated injury in older people. 4 Older people in residential aged care facilities (RACFs) are usually the frailest, with multiple comorbidities and functional and cognitive impairment. 5 Moreover, polypharmacy is common in older residents, as half of this cohort usually take nine or more medicines. 6 In the United States, the occurrence of medicines-related harm in RACFs is as high as 10.8 events per 100-resident months. 7 Medicines-related harm constitutes a significant imposition on the Australian healthcare system, 8 where the annual cost of medication-related hospital admissions is approximately $1.4 billion, which is equivalent to 15% of total Pharmaceutical Benefits Scheme expenditure. 9,10 In 2022, it was estimated that 250 000 Australians are hospitalized every year due to medicines-related harm. 9 Around one in five hospitalizations among older Australians are medicines-related 9 . Similarly, a previous study in Australia reported that 46% of the hospitalizations among older residents were due to potentially suboptimal use of medicines. 11 In addition, many aged care residents were on fall-risk drugs and visited hospital with fractures. Discontinuation or dose reduction in fall-risk drugs significantly reduces the occurrence of falls in older people. 12 Since medicines-related harm frequently occurs in vulnerable older residents, pharmacists working in the aged care sector may play an important role in reducing the incidence of these harms and improving medication use in older people living in RACFs. 3 In RACFs, the skills of healthcare professionals, particularly when working as a team, can contribute to improved patient outcomes. 13 A study reported that the lack of accessibility to pharmacists is an important factor affecting medication safety and quality use of medicines in RACFs. 14 A recent review indicated that pharmacist interventions appear to improve medication safety in older residents based on observed reductions in medicines-related harm, particularly when the provision of care involves multidisciplinary collaboration. 3 Many factors can affect the outcomes of evidencebased interventions; however, the success of implementation efforts depends on a careful assessment of barriers to, and facilitators of, the behavior to be changed. 15 In Australia, little is known about the barriers and facilitators experienced by pharmacists in reducing medicines-related harm in RACFs. No study has extensively used a qualitative approach to investigate the views of pharmacists toward reducing the risk of medicines-related harm in aged care residents. Therefore, we aimed to explore and understand the views of pharmacists providing services in RACFs on medicines-related harm, harm reduction strategies, associated potential risk factors, and barriers and facilitators to reducing medicines-related harm in aged care residents.

| ME THODS
The qualitative approach selected for this research was informed by grounded theory. We used a qualitative thematic analysis using an inductive approach to explore the views of pharmacists toward reducing the risk of medicines-related harm in older residents. Face-toface semi-structured interviews using an interview guide (Table S1) were conducted via Zoom with pharmacists across Australia providing services (e.g., through the provision of Residential Medication Management Reviews (RMMRs), supplying medications to RACFs, or being an embedded/on-site pharmacist) to RACFs. An RMMR is conducted by an accredited pharmacist and facilitates the quality use of medicines and helps reduce the occurrence of medicines-related harm in older Australians living in government-funded RACFs. 16 The interview guide was prepared based on the literature that aligns with our study objectives. This aided in the development of our list of questions for the pharmacists working in RACFs as well as the identification of significant themes and subjects that were pertinent to our research question. After going through this process, we came up with an outline of the main themes or topics we wanted to address in the interviews. This made it easier to plan and formulate interview questions and ensured that all relevant subjects were covered. We avoided leading questions and questions that can be responded with a simple "yes" or "no" in order to ensure that the questions are clear, suc- cinct, and open-ended to allow for a deep and in-depth investigation of the subject. To guarantee that the questions are focused, relevant, and appropriate, we also revised and improved them through expert opinion and feedback from pharmacists providing services to RACFs.
Probes, follow-up enquiries, or other prompts were also included in the questions to nudge respondents to elaborate on their responses and offer more thorough details. In order to find any problems or potential areas for improvement, we also pilot-tested the interview guide with a small number of pharmacists. The questions covered: thoughts on medicines-related harm, pharmacist-led interventions to improving medication safety, harm reduction strategies currently in use, potential risk factors associated with medicines-related harm, and barriers and facilitators to reducing medicines-related harm in older residents.
Qualitative data were audio-recorded, transcribed, and analyzed using the thematic analysis approach explained by Braun and Clarke. 17 All participants had an opportunity to review the text transcription for accuracy within 2 weeks of the interview prior to thematic analysis, although only one participant accepted this offer. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) were followed in the reporting of the research findings. 18

| Participant recruitment
As a guide, it is recommended that qualitative studies require a minimum sample size of at least 12 to be likely to reach data saturation. 19 A convenience sampling technique was used to recruit 15 pharmacists providing services to RACFs, who gave their consent via an ongoing survey regarding the perceptions and practices of pharmacists toward reducing medicines-related harms in aged care residents. A web link to the survey questionnaire was shared with the pharmacists via Australian professional pharmacy organizations (e.g., Australian Association of Consultant Pharmacy, Pharmacy Guild of Australia, Professional Pharmacists Australia, and Pharmaceutical Society of Australia), Pharmacy Daily (an online publication), and social media groups (e.g., LinkedIn, Facebook, and Twitter). At the end of the survey questionnaire, pharmacists had an opportunity to complete a separate recruitment form for the follow-up interview to share their experiences providing services to RACFs. All participants were emailed an information sheet about the research and a consent form prior to the interview. We provided a $50 gift card to each participant.

| Analysis
The data were analyzed using NVivo QSR 10 after interviews were transcribed. Thematic analysis was performed via inductive coding and the creation of sub-themes and themes. Data coding was performed independently by two authors (SA and MS). Together, the authors (CC, MS, SA, and GP) discussed and revised the final coding, and sub-theme and theme wording and structure.

| Ethics
Approval for this study was obtained from the Tasmanian Human Research Ethics Committee (Reference: H0026755).

| RE SULTS
Fifteen interviews were conducted; 11 pharmacists were providing RMMRs (and one of these also supplied medication to RACFs), one worked as a medication supply pharmacist, two worked as on-site pharmacists in RACFs, and one worked in a transition care program.
Many pharmacists worked in metropolitan areas (n = 10, 67%). Most pharmacists were female (n = 11, 73%) and were between 30 and 59 years old. Two-thirds of the pharmacists provided services to more than three RACFs. The median years of experience of providing services to RACFs was 13 years (range, 5-22 years), and 14 pharmacists (93%) were accredited to perform RMMRs. Eight pharmacists (54%) performed more than 20 RMMRs monthly. Pharmacists were from six states of Australia, as detailed in Table 1.
Several themes were identified regarding medicines-related harm in aged care residents (Table S2).

| Common medicines-related harms
Most pharmacists reported that falls, anticholinergic effects, and adverse effects on the central nervous system (CNS), such as sedation and confusion, were common medicines-related harms in older residents. Many pharmacists discussed that the occurrence of fall was a serious medicines-related injury in frail older residents with multiple comorbidities. Other pharmacists reported that medicines acting on the nervous system were causes of sedation and confusion, with the subsequent risk of falls and their sequelae.
Probably drug-induced sedation, yeah, you know, increasing the risk of confusion increasing the risk of fall.

(P14, RMMR pharmacist).
Several pharmacists pointed out that strong anticholinergics were involved in causing severe confusion as these are CNS-acting medicines.
Probably the use of anticholinergic agents such as oxybutynin, where they get very, very confused with it. (P4, RMMR pharmacist). Pharmacists expressed that the inappropriate prescribing of medicines increases the risk of harm in older residents.

We want the best medication regimen for a particular person. […] multiple inappropriate medications is prob-
ably the most important factor that's causing and resulting in adverse outcomes in our aged care sector. (P8,

RMMR pharmacist).
Pharmacists said that the reconciliation of medicines is crucial as medicines are not properly reviewed after residents' admission into RACF. Additionally, sometimes aged care residents take medicines for several months or years that were earlier prescribed for a short duration and it occurs because of infrequent review of medicines. Pharmacists also mentioned that infrequent and poorly written medication reviews impede efforts to improve medication safety in older residents.

| GPs and systems facilitators
Pharmacists reported the following GPs and systems-related facilitators to improve medication safety: collaboration with GPs, provision of education to the GP, provision of funding/increased remunera- Pharmacists also mentioned that the provision of education to GPs is critical as they are not experts in pharmacotherapy.

| Resources for reducing medicines-related harm
Participants discussed numerous resources for reducing medicines-

| DISCUSS ION
Pharmacists can play a key role in reducing the occurrence of medicines-related harm in older people living in RACFs. 3 Their insights are needed before developing an effective tailored intervention toward reducing the risk of medicines-related harm in this cohort.
Pharmacists reported that polypharmacy, PIMs, anticholinergic effects of drugs, and sedative load are medicines-related risk factors for harm in older residents, as similarly identified in previous reports. [20][21][22] In this study, pharmacists also reported other medicines-related risk factors such as medicines reconciliation and the risk of commencing new drugs. Medication reconciliation is recognized as an effective approach for preventing medicines-related harm. 23 Medication order discrepancies can happen during the transition of care due to infrequent communication between nurses, pharmacists, and GPs. 24 Similarly, effective communication between pharmacists, GPs, and aged care staff based on evidence-based information could increase the uptake of pharmacists' recommendations, such as discontinuation of unnecessary medicines and dose reductions. 25 Pharmacists often stated that GPs and aged care staff do not accept their recommendations, impeding efforts to improve medication safety in older residents. Pharmacists stated the need for strong interdisciplinary collaboration between GPs, pharmacists, and aged care staff, to improve medication safety in RACFs. A lack of communication between healthcare professionals caring for older residents is a significant factor influencing medication safety and the quality use of medicines within RACFs. 14 A collaborative pharmacist-initiated medication review with a GP exhibited a significant reduction in medicines-related injury in aged care residents. 26 A multidisciplinary case conference between GPs, pharmacists, and aged care staff is an effective strategy for improving medication safety among older residents. 27 The provision of training in effective communication between healthcare professionals providing services to RACFs may improve the quality use of medicines in older residents.
Overall, pharmacists believed that medicines-related injury is multifactorial and a significant problem in Australian RACFs.
Pharmacists in our study frequently encountered falls in frail older residents with multiple comorbidities. Furthermore, pharmacists discussed that inappropriate use of antipsychotics and anticholinergics increased the risk of medicines-related harm in older residents.
A previous study in Finland reported that multiple comorbidities are associated with the risk of recurrent falling. 28 Fall-risk drugs, such as anticholinergics, opioids, benzodiazepines, antidepressants, and antipsychotics, are frequently prescribed for older residents. 29 It is crucial to minimize use of these drugs to prevent falls and fallassociated injuries. 12 A recently published Australian Aged Care Royal Commission report recommended stricter requirements for prescribing antipsychotics for people living in RACFs. 30 The Royal Commission advocated that older residents should be individually reviewed by a psychiatrist preceding the initiation of antipsychotics. 30  The systematic problems such as inadequate funding for the aged care sector contribute to improper care of older residents. 30 Pharmacists indicated that insufficient funding and remuneration for pharmacists are barriers to improving medication safety in older residents. The Royal Commission also acknowledged insufficient government funding for aged care and indicated that the provision of care for older residents is influenced by insufficient funding arrangements. 30 Pharmacists are pharmacotherapy experts and are well-suited to conduct medication reviews and ascertain inherent causes of medicines-related problems and provide solutions to prevent them. 36

| Strengths and limitations
This study is the first of its kind that explored the views of Australian pharmacists providing services in RACFs toward reducing the risk of medicines-related harm in aged care residents. This study also has certain limitations. A qualitative study may not demonstrate whether pharmacists can improve health outcomes in older residents, and a randomized controlled trial is needed to yield positive results. Other healthcare professionals were not interviewed; only pharmacists were, which may have affected the extraction of other barriers and facilitators that may have existed but were missed. However, the interpretation of the interviews could be subjective due to the qualitative nature of the study; therefore, some caution is needed.

| Implications for clinical practice and future research
Since medication use is a serious ongoing concern in Australian RACFs, this qualitative study facilitated exploring safety issues and

| CON CLUS IONS
Pharmacists believed that the irrational use of medicines increases harm in aged care residents and medicine-specific (e.g., sedative load) and patient-specific risk factors (e.g., renal impairment) are associated with injuries in residents. To reduce medicines-related harm, the participants highlighted the need for increased funding for pharmacists, improving all stakeholders' awareness about medicines-associated harms through education, and ensuring collaboration between healthcare professionals caring for aged care residents.

ACK N OWLED G M ENTS
Open access publishing facilitated by University of Tasmania, as part of the Wiley -University of Tasmania agreement via the Council of Australian University Librarians.

FU N D I N G I N FO R M ATI O N
This research received no specific grant from any funding agency in public, commercial or not-for-profit sectors.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare that they have no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
All data are available in tables and Data S1.