Medicines play an integral role in disease management, yet can be associated with significant problems, especially in vulnerable older people (Elliott RA, 2014). Older people are more prone to the side effects of medicines due to age-related changes in pharmacokinetics and pharmacodynamics, the presence of co-morbidities, and the use of multiple medicines (Eshetie et al., 2018). Medicines-related harm is any injury resulting from the use of medicines (Gyllensten et al., 2013; EUROmediCAT, 2015); it is recognised as a major healthcare concern in older people and places a substantial economic burden on the health system (Cahir et al., 2019). Medicines-related harm is a common cause of hospitalisations in older people, and the annual cost of medication-related hospital admissions is about $1.4 billion in Australia (Parameswaran Nair et al., 2016; Lim et al., 2022). Potentially inappropriate medication (PIMs) are defined as “medications that should be avoided due to their risk which outweighs their benefit and when there are equally or more effective but lower risk alternatives available” (Alhawassi et al., 2019). In particular, the risk of medicines-related harm is high in residential aged care facilities (RACFs) because of, among other reasons, the use of PIMs and the overall magnitude of medicines usage (Ali et al., 2021). A review indicated that half of older residents in RACFs are prescribed at least one PIM (Morin et al., 2016).

Pharmacists are recognised as experts in pharmacotherapy and could potentially prevent medicines-related harm in older people (Lee et al., 2015). A pharmacist-conducted medication review is a common intervention for reducing medicines-related harm in aged care residents (Ali et al., 2021). A previous study in Australia reported that the provision of pharmacist-led medication reviews appears to decrease the risk of mortality in residents (Sluggett et al., 2022). Evidence also indicates that the lack of accessibility to pharmacists is an important factor affecting the rational use of medicines in RACFs (Al-Jumaili and Doucette, 2017). However, the services offered by pharmacists to RACF patients and the impact of these services are still not clear (Lee et al., 2019). Medication management in RACFs is an ongoing concern (Kosari et al., 2021) and in Australia the final report of the Royal Commission into Aged Care Quality and Safety highlighted significant problems with the treatment of older people in RACFs, particularly the overuse of antipsychotic drugs (Royal Commission into Aged Care Quality and Safety, 2021). The report made numerous recommendations about the increased participation of pharmacists in medication management in aged care (Royal Commission into Aged Care Quality and Safety, 2021).

Previous studies in Australian RACFs focused on determining pharmacists’ views towards antibiotic prescribing (Lim et al., 2014) and monitoring of psychotropics (Langford et al., 2021). Overall, there is a lack of evidence regarding perceptions and practices of pharmacists providing services in RACFs towards improving medicines use. Understanding current practices and perceptions of pharmacists providing services in RACFs towards reducing the risk of medicines-related harm may provide insights to enhance safety and mitigate medicines-related morbidity and mortality. Therefore, we aimed to investigate pharmacists’ perceptions and practices towards reducing medicines-related harm among older people living in RACFs. As a secondary objective, we compared the responses based on pharmacists providing varying services to RACFs, e.g., through the provision of Residential Medication Management Reviews (RMMRs), supplying medications to RACFs, or being an embedded/in-house pharmacist, for assessing the differences in their perceptions and practices towards reducing medicines-related harm among residents. An embedded pharmacist performs medication management (e.g., medicine reviews) and quality improvement activities (e.g., revising medicine administration protocols), and educates aged care staff regarding medicines and their use. In Australia, an accredited pharmacist, usually on a visitational basis, conducts RMMRs that facilitate the quality use of medicines and help reduce the incidence of medicines-related injury in government-funded RACFs (Pharmacy Programs Administrator, 2022). This includes sharing a medication review report with each resident’s general practitioner to encourage implementation of the pharmacist’s recommendations for improving medicines management (Pharmaceutical Society of Australia, 2019). An RMMR pharmacist provides services to RACFs remotely or in a visiting capacity. In Australia, the aged care pharmacist services are implemented and organised through a funding provided by the Australian government (Kosari et al., 2021). All RACFs do not have a RMMR pharmacist as the level of pharmacy support could vary between RACFs and is subject to the discretion of the RACF management and the specific needs of the residents (Kosari et al., 2021). Similarly, some RACFs can choose to contract with a RMMR pharmacist for regular medication reviews, while others may rely on other healthcare professionals to manage residents’ medication needs. The role of Australian aged care supply pharmacists is to ensure that older people in RACFs receive appropriate and safe medication management (Pharmaceutical Society of Australia, 2019). Moreover, the supply pharmacists are responsible for managing the supply and dispensing of medicines, as well as ensuring that aged care residents receive the right medicine at the right time. This includes monitoring the effectiveness of medicines, identifying any potential medicines-related harm, and ensuring that residents receive appropriate support and advice to manage their medicines (Tait et al., 2021). A supply pharmacist also works closely with other healthcare professionals, including doctors and nurses, to ensure that patients receive comprehensive and coordinated care (Tait et al., 2021).

A cross-sectional national survey was conducted between February 2022 and August 2022. Pharmacists across Australia providing clinical or supply services to RACFs were the target population.

From February to August 2022, 209 pharmacists completed the survey. One hundred and forty-six were RMMR pharmacists and twelve were embedded pharmacists within RACFs; we combined these groups as their roles are relatively similar and distinct from supply pharmacists. The demographics of the pharmacists are detailed in Table 1. The median years of experience in providing services to RACFs was 7 years (range, 3–15 years), and 173 pharmacists (83%) were accredited to perform RMMRs. About half of the pharmacists provided services to more than three RACFs.

Table 2 shows the comparison of responses between RMMR/embedded and supply pharmacists regarding perceptions, practices, risk factors and strategies in reducing medicines-related injury in RACFs. We merged the responses of the Likert scale into two categories - scoring ≤3 (disagree) and ≥4 (agree). Many of the pharmacists believed that medicines-related harms are common (n = 174, 83%) and only half believed that safe medication management is usually practiced in RACFs (n = 106, 51%). Almost all pharmacists agreed regarding the risk factors for medicines-related harm in aged care residents, such as polypharmacy, PIMs, dementia, recent drug changes, shortage of aged care staff, transitions of care, renal impairment, and specific drug use (e.g., antipsychotics and anticholinergics). A minority of respondents agreed that antibiotics (n = 86, 41%) and antipsychotics (n = 89, 42%) are usually prescribed in appropriate circumstances in older residents.

As with risk factors, the pharmacists displayed high agreement regarding potential strategies (e.g., presence of embedded pharmacists in RACFs, frequent pharmacist-led medication reviews, collaborative medication reviews with a general practitioner, and educating aged care staff) for reducing medicines-related harm in aged care residents. Enhancing collaboration between pharmacists and aged care staff was acknowledged by almost all pharmacists as a key strategy to reduce this harm in older residents (n = 199, 95%). Most pharmacists also agreed that RMMRs prevent medicines-related harm (n = 182, 87%), although only 62% of the RMMR/embedded pharmacists believed that their recommendations during RMMRs were typically accepted by general practitioners. Most pharmacists, particularly within the RMMR/embedded pharmacist group, agreed that aged care management personnel consider pharmacists’ suggestions for reducing medicines-related harm in residents (n = 172, 82%), but few agreed that pharmacists have enough time to participate in medicines-related harm reduction services (n = 60, 28%).

Only half of the pharmacists indicated that they routinely participate in harm reduction services (n = 110, 53%); this was lower for supply pharmacists (29%) relative to the RMMR/embedded pharmacists (60%). Also, a significantly lower proportion of the supply pharmacists reported that they were familiar with medication appropriateness tools (e.g., Beers criteria and anticholinergic drug burden) and routinely utilised these tools. Overall, very few supply pharmacists participated in harm reduction services, reported adverse drug reactions to the Australian Therapeutic Goods Administration, and utilised tools to predict the risk of medicines-related harm. There was a large difference in the proportions of supply and RMMR/embedded pharmacists (84% and 45%, respectively) who agreed that supply pharmacists detect medicines-related harms whilst supplying medicines. Most pharmacists indicated that they routinely recommend deprescribing interventions (n = 170, 81%); this was lower for supply pharmacists (47%) relative to the RMMR/embedded pharmacists (92%).

The role of pharmacists in aged care is evolving globally and may be critical in reducing the incidence of medicines-related injury in aged care residents (Ali et al., 2021; Haider et al., 2021). Knowing the perceptions and current practices of pharmacists providing services in RACFs should be useful when developing interventions towards reducing the risk of medicines-related harm in older residents.

Most pharmacists agreed that medicines-related harm is highly prevalent in residents. Aged care residents take many medicines for their multiple morbidities, and it is a responsibility of all stakeholders involved in managing older residents to ensure the safe medication management (Department of Health and Aged Care, 2022). All stakeholders should follow the guiding principles for medication management in RACFs (e.g., person-centred care, medication reconciliation, and selection of medicines) issued by the Australian Government Department of Health and Ageing.

Pharmacists believed that older residents frequently experience medicines-related harm due to factors such as polypharmacy, PIMs, anticholinergic drug use and multi-morbidity. They believed increased collaboration between pharmacists and aged care staff would reduce these harms. The 2021 Australian Aged Care Royal Commission report recommended increased communication and collaboration between aged care staff and other healthcare professionals, such as general practitioners and pharmacists providing services in RACFs (Royal Commission into Aged Care Quality and Safety, 2021). In New Zealand, the collaborative pharmacist-led medication reviews with a general practitioner were associated with a significant reduction in falls and adverse effects in older residents (Ailabouni et al., 2019). However, only 62% of the RMMR/embedded pharmacists in our study believed that their recommendations during RMMRs were typically accepted by general practitioners. The infrequent uptake of pharmacists’ recommendations can act as a barrier in reducing medicines-related harm in residents; improving uptake of pharmacists’ recommendations during RMMRs improves safe and effective use of medicines (Cross et al., 2022).

Relatively few pharmacists in our study agreed that antibiotics and antipsychotics are frequently prescribed in appropriate circumstances in Australian aged care residents. The RedUSe intervention, comprising multidisciplinary case review, provision of education to the staff, and audit and feedback, has recently been introduced in RACFs to reduce inappropriate antipsychotic prescribing (Westbury et al., 2018). Antibiotic stewardship could similarly help to reduce inappropriate prescribing of antibiotics and the occurrence of antibiotic-associated harm in residents (Ali et al., 2021).

Most RMMR/embedded pharmacists believed that supply pharmacists do not usually identify medicines-related injury whilst supplying medicines. Many supply pharmacists in our study were not familiar with tools, such as the Beers criteria and anticholinergic drug burden scale, to predict the risk of medicines-related harm in aged care residents. In addition, very few supply pharmacists regularly utilised these tools or routinely engaged in harm reduction services. Similarly, a Malaysian study reported that only 27% of community pharmacists were familiar with Beers criteria and 17% frequently used this tool in practice (Foong et al., 2020). Educating supply pharmacists regarding these medication appropriateness tools may facilitate improving medication safety whilst supplying medicines. In essence, their role should not be simply restricted to providing medicines without any clinical involvement. Lack of time is the greatest barrier to pharmacist participation in medication safety services (Li et al., 2018).

In Australia, pharmacists usually provide services in RACFs via supplying medicines and consultancy, and these roles are executed remotely or in a visiting capacity (Sluggett et al., 2017). There is a need to physically integrate pharmacists within RACF teams (Kosari et al., 2021). Embedded pharmacists can facilitate the quality use of medicines in RACFs (McDerby et al., 2020a). In 2023, all government funded RACFs across Australia will be able to engage a part-time embedded pharmacist (Cross et al., 2022). A recent Australian study reported that pharmacist integration for 15 h each week in RACFs increased the provision of education for the aged care staff (McDerby et al., 2020b).

Pharmacists agreed that aged care residents frequently experience medicines-related harm, but their involvement in medicines-related harm reduction services was relatively limited. Initiatives to engage pharmacists in harm reduction services and educate aged care staff regarding safe medication management may improve residents’ health outcomes. Medicines use in aged care residents can be optimised by the presence of embedded pharmacists in a team environment, provision of education to aged care personnel, and collaborative medication reviews with general practitioners. Ideally, supply pharmacists would also play a greater role in accepting responsibility for the risks posed by the medicines they provide to RACFs. Future research is needed to assess the impact of educating aged care staff about safe medication management on residents’ health outcomes.