A Cross-Sectional Study on Medication Errors in Home Health Care: The Role of Caregiver Type at a Military Hospital in Riyadh, Saudi Arabia

This cross-sectional study conducted at a military hospital in Riyadh reveals that medication errors in home health care are significantly more prevalent among patients with informal caregivers compared to formal ones, underscoring the urgent need for caregiver training and a national medication tracking system to enhance patient safety in Saudi Arabia.

The Gist

Imagine your home as a busy kitchen where a very important chef (the patient) needs to eat a specific, complex meal every day to stay healthy. This meal isn't just food; it's a mix of different medicines. Now, imagine that someone else is in charge of cooking and serving this meal. Sometimes, that person is a professional chef with years of training (a formal caregiver). Other times, it's a loving family member who is trying their best but has never taken a cooking class (an informal caregiver).

This study is like a health inspector walking into 503 of these "medication kitchens" in Riyadh, Saudi Arabia, to see how well the meals are being prepared.

Here is the story of what they found, broken down simply:

1. The Setting: A Free-For-All Pantry

In Saudi Arabia, getting medicine from government hospitals is like getting free groceries at a massive, unlimited buffet. This is great because everyone can eat! But, because there is no single "master list" tracking who took what, people sometimes end up with too much food.

• The Problem: Patients might get the same medicine from two different doctors, or they might keep old, expired medicine in the cupboard because "it was free, so why throw it away?"
• The Analogy: It's like having three different delivery services drop off pizza at your door every week. Soon, your fridge is overflowing with cold, expired pizza, and you don't know which slice is safe to eat.

2. The Main Characters: Who is Cooking?

The researchers looked at who was managing the medicine:

• Formal Caregivers: These are trained nurses or professionals. They know the recipe, the timing, and the safety rules.
• Informal Caregivers: These are family members (spouses, children, siblings). They love the patient deeply, but they often haven't been trained on the complex "recipe" of managing multiple drugs.

The Big Discovery:
The study found that 60% of the patients were being cared for by family members (informal). When the researchers checked the "kitchens," they found a huge difference in safety:

• Professional Chefs (Formal): Made mistakes only about 19% of the time.
• Family Chefs (Informal): Made mistakes about 46% of the time.

That's more than double the error rate! It's not that family members care less; it's that managing 5+ different medicines a day is like trying to juggle 10 flaming torches without ever having practiced.

3. The Types of Mistakes (The "Burnt Toast")

What kind of errors were happening?

• Wrong Timing (22.5%): Taking the medicine at 8:00 AM when it should be 8:00 PM. It's like eating breakfast for dinner.
• Wrong Storage (14.6%): Leaving medicine in a hot, humid bathroom cabinet instead of a cool, dry place. It's like leaving chocolate in the sun; it melts and becomes useless.
• Wrong Dose (13.2%): Giving too much or too little.
• Expired Medicine (2%): Using medicine that has passed its "best by" date.

4. Why Does This Happen?

The study points out a few reasons why the "family chefs" are struggling:

• Lack of Training: They aren't taught how to handle complex medical schedules.
• The "Free Medicine" Trap: Because medicine is free and there's no central computer tracking it, families end up with duplicate bottles. They get confused about which bottle to use and when to throw the old one away.
• Complexity: The patients are elderly (average age 80) and often have many chronic diseases, meaning they are taking a lot of pills at once.

5. The Solution: Teaching the Family Chefs

The researchers conclude that we can't just blame the family. The system needs to change.

• Training: We need to teach family members how to be safe "medication managers." It's like giving them a cooking class before they take over the kitchen.
• Better Systems: Saudi Arabia needs a "Master List" (a national tracking system) so that if a patient gets medicine at Hospital A, Hospital B knows about it. This stops the "pizza overload" and prevents dangerous duplicates.
• Clear Rules: We need better ways to dispose of old medicine so it doesn't sit in the cupboard waiting to cause harm.

The Bottom Line

This study is a wake-up call. While loving family members are doing a heroic job, they are often set up to fail by a system that is too complex and lacks proper tracking. To keep our elderly loved ones safe at home, we need to train the family and fix the system so that the "medication kitchen" is a safe place, not a source of danger.

Technical Summary

1. Problem Statement

Medication safety in home health care (HHC) is a critical global concern, particularly for older adults managing chronic conditions and polypharmacy (taking five or more medications). In Saudi Arabia, specific systemic factors exacerbate these risks:

• Free Medication Dispensing: Under the National Guard Health Affairs (NGHA), medications are provided free of charge, which can lead to the accumulation of duplicate medications and excessive storage at home.
• Lack of Unified Tracking: There is no national software system to track medication distribution across different healthcare providers. Patients may receive overlapping prescriptions from different institutions, leading to duplication and potential interactions.
• Caregiver Training Gap: A significant portion of home care is provided by informal caregivers (family members) who lack formal medical training, potentially delaying the implementation of safe medication management practices.

The study aims to quantify the prevalence of medication errors in the home setting and determine the statistical association between the type of caregiver (formal vs. informal) and the incidence of these errors.

2. Methodology

• Study Design: Cross-sectional study conducted between January and December 2024.
• Setting: Home Health Care (HHC) program at King Abdulaziz Medical City, a military hospital under NGHA in Riyadh, Saudi Arabia.
• Participants:
  • Sample: 503 patients enrolled in the HHC program.
  • Inclusion Criteria: Saudi nationals, aged ≥18, with at least one chronic disease, taking ≥5 medications simultaneously, dependent on assistance for daily living, and enrolled in HHC for ≥4 weeks.
  • Caregiver Classification: Patients were categorized based on their primary caregiver: Formal (trained healthcare professionals) or Informal (family members or untrained individuals).
• Data Collection:
  • Nurses conducted routine home visits using a structured medication assessment template.
  • Data covered 2,515 individual medication entries.
  • The template assessed: Medication type, timing accuracy, dosage accuracy (correct, missing, over/under), storage conditions, expiration status, and caregiver type.
• Statistical Analysis:
  • Descriptive statistics (frequencies, percentages, means) were used for sample characterization.
  • Chi-square tests were employed to examine the association between caregiver type and medication errors.
  • Significance level set at $p < 0.05$.
  • Software: SAS 9.4.

3. Key Results

Demographics:

• Patient Age: Mean age of 79.8 years (Range: 48–99).
• Caregiver Distribution: 60.04% ($n=302$) were cared for by informal caregivers; 39.96% ($n=201$) by formal caregivers.
• Gender: 52.7% Female, 47.3% Male.

Medication Error Prevalence (Total $n=2,515$):

• Overall Error Rate: 35.31% of medication records contained at least one error.
• Specific Error Types:
  • Timing: 22.5% were administered at incorrect times (most frequent error).
  • Storage: 14.6% were stored improperly.
  • Dosage: 13.2% had dosage errors (7.9% over/under-dose, 5.3% missing dose).
  • Expiration: 2.0% were expired.
• Common Drug Categories: Antihypertensives (15.71%), Gastrointestinal agents (12.56%), and Cardiovascular drugs (11.69%).

Association with Caregiver Type:

• Informal Caregivers: 46.01% of medications managed by informal caregivers resulted in errors ($n=697$).
• Formal Caregivers: Only 19.10% of medications managed by formal caregivers resulted in errors ($n=191$).
• Statistical Significance: The difference in error rates between the two groups was highly significant ($p < 0.0001$).

4. Key Contributions

• Quantification of Informal Care Risk: The study provides empirical evidence that informal caregivers in the Saudi context are associated with a 2.4-fold higher risk of medication errors compared to formal caregivers.
• Systemic Insight: It highlights how the "free medication" policy, while beneficial for access, inadvertently contributes to medication duplication and storage hazards due to the lack of a centralized tracking system.
• Error Typology: It identifies timing errors as the most prevalent issue in the home setting, followed by storage and dosage issues, offering a prioritized target for intervention.
• Contextual Relevance: It addresses a gap in literature regarding medication safety specifically within the unique healthcare infrastructure of Saudi Arabia (NGHA system).

5. Significance and Implications

• Policy Reform: The findings strongly advocate for the implementation of a unified national medication tracking system to prevent duplication and manage inventory across different healthcare providers.
• Targeted Interventions: There is an urgent need for structured training programs for informal caregivers (family members) to bridge the knowledge gap regarding dosage, timing, and storage.
• Patient Safety: Reducing medication errors in the home is critical for preventing adverse drug events, hospital readmissions, and improving the quality of life for the aging Saudi population.
• Future Research: The authors recommend longitudinal studies to track error trends over time and the evaluation of specific educational interventions for caregivers.

Limitations: The study is limited to a single military hospital, which may affect generalizability to the broader Saudi population. Additionally, the cross-sectional design captures a snapshot in time and may miss intermittent errors occurring between nurse visits.