The American Journal of Medicine
Volume 109, Issue 2 , Pages 87-94 , 1 August 2000

Incidence and preventability of adverse drug events in nursing homes

  • Jerry H Gurwitz, MD

      Affiliations

    • Requests for reprints should be addressed to
    • Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA
    • Corresponding Author InformationJerry H. Gurwitz, MD, Meyers Primary Care Institute, Fallon Healthcare System and University of Massachusetts Medical School, 100 Central Street, Worcester, Massachusetts 01608
  • ,
  • Terry S Field, DSc

      Affiliations

    • Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA
  • ,
  • Jerry Avorn, MD

      Affiliations

    • Brigham and Women’s Hospital (JA, DWB), Boston, Massachusetts, USA
    • Harvard University (JA, ACE, DWB), Boston, Massachusetts, USA
  • ,
  • Danny McCormick, MD, MPH

      Affiliations

    • Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA
  • ,
  • Shailavi Jain, RPh

      Affiliations

    • Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA
  • ,
  • Marie Eckler, RN, MS

      Affiliations

    • Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA
  • ,
  • Marcia Benser, RN, MS

      Affiliations

    • Meyers Primary Care Institute, the Fallon Healthcare System, and the University of Massachusetts Medical School (JHG, TSF, DM, SJ, ME, MB), Worcester, Massachusetts, USA
  • ,
  • Amy C Edmondson, PhD

      Affiliations

    • Harvard University (JA, ACE, DWB), Boston, Massachusetts, USA
  • ,
  • David W Bates, MD

      Affiliations

    • Brigham and Women’s Hospital (JA, DWB), Boston, Massachusetts, USA
    • Harvard University (JA, ACE, DWB), Boston, Massachusetts, USA

Received 14 September 1999 ,Revised 3 April 2000 ,Accepted 3 April 2000.

References 

  1. Strahan GW. An Overview of Nursing Homes and Their Current Residents: Data from the 1995 National Nursing Homes Survey. Advance Data from Vital and Health Statistics, No. 280. Hyattsville, Md: National Center for Health Statistics, 1997.
  2. Bernabei R, Gambassi G, Lapane K, et al. Characteristics of the SAGE database: a new resource for research on outcomes in long–term care. J Gerontol Series A, Biological Sciences, Medical Sciences. 1999;54:M25–M33.
  3. Shorr RI, Fought RL, Ray WA. Changes in antipyschotic drug use in nursing homes during implementation of the OBRA-87 regulations. JAMA. 1994;271:358–362
  4. Beers M, Avorn J, Soumerai SB, et al.  Psychoactive medication use in intermediate-care facility residents. JAMA. 1988;260:3016–3020
  5. Pickering TD, Gurwitz JH, Zaleznick D, et al.  The appropriateness of oral fluoroquinolone prescribing in the long-term care setting. J Am Geriatr Soc. 1994;42:28–32
  6. Gurwitz JH, Noonan JP, Soumerai SB. Reducing the use of H2-receptor antagonists in the long-term care setting. J Am Geriatr Soc. 1992;40:359–364
  7. Ray WA, Federspiel CF, Schaffner W. A study of antipsychotic drug use in nursing homes (epidemiologic evidence suggesting misuse). Am J Public Health. 1980;70:485–491
  8. Svarstad BL, Mount JK. Nursing home resources and tranquilizer use among the institutionalized elderly. J Am Geriatr Soc. 1991;39:869–875
  9. Beers MH, Ouslander JG, Fingold SF, et al.  Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med. 1992;117:684–689
  10. Gerety MB, Cornell JE, Plichta DT, Eimer M. Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc. 1993;41:1326–1332
  11. Gurwitz JH, Sanchez-Cross MT, Eckler MA, Matulis J. The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994;42:33–38
  12. Bates DW, Cullen DJ, Laird N, et al.  Incidence of adverse drug events and potential adverse drug events (implications for prevention). JAMA. 1995;274:29–34
  13. Bates DW, Boyle DL, Vander Vliet MB, et al.  Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:199–205
  14. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311–1216.
  15. Leape LL, Cullen DJ, Clapp MD, et al.  Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282:267–270
  16. Beers MH, Ouslander JG, Rollingher I, et al.  Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151:1825–1832
  17. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med. 1997;157:1531–1536
  18. Gurwitz JH. Suboptimal medication use in the elderly. The tip of the iceberg. JAMA. 1994;272:316–317
  19. Folli HL, Poole RI, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics. 1987;79:781–722.
  20. Dubois RW, Brook RH. Preventable deaths (who, how often, and why). Ann Intern Med. 1998;190:582–589
  21. Katz S, Ford AB, Moskowitz RW, et al.  Studies of illness in the aged (the index of ADL. A standardized measure of biological and psychosocial function). JAMA. 1963;185:914–919
  22. Department of Health, Education, and Welfare . Skilled nursing facility standards for certification and participation in Medicare and Medicaid programs. Fed Regist. 1974;39:2238
  23. Rosner B. Fundamentals of Biostatistics 3rd ed. Boston, Mass: PWS-Kent; 1990.
  24. Phillips DP, Christenfeld, N, Glynn LM. Increase in U.S. medication-error deaths between 1983 and 1993. Lancet. 1998;351:643–644, 1983.
  25. Rango N. Nursing home care in the United States. N Engl J Med. 1982;307:883–889
  26. Elon R, Paulson LG. The impact of OBRA on medical practice within nursing facilities. J Am Geriatr Soc. 1992;40:958–963
  27. Ray WA, Taylor JA, Meador KG, et al.  A randomized trial of a consultation service to reduce falls in nursing homes. JAMA. 1997;278:557–562
  28. Avorn J, Soumerai SB, Everitt DE, et al.  A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med. 1992;327:168–173
  29. Ray WA, Taylor JA, Meador KG, et al.  Reducing antipsychotic drug use in nursing homes. A controlled trial of provider education. Arch Intern Med. 1993;153:713–721
  30. Gurwitz JH, Monette J, Rochon PA, et al.  Atrial fibrillation and stroke prevention with warfarin in the long-term care setting. Arch Intern Med. 1997;157:978–984
  31. Dey AN. Characteristics of Elderly Nursing Home Residents: Data from the 1995 National Nursing Home Survey. Advance Data from Vital and Health Statistics, No. 289. Hyattsville, Md: National Center for Health Statistics; 1997.
  32. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320:53–56
  33. Leape LL. Error in medicine. JAMA. 1994;272:1851–1857
  34. Leape LL, Bates DW, Cullen DJ, et al.  Systems analysis of adverse drug events. JAMA. 1995;274:35–43
  35. Horton R. The uses of error. Lancet. 1999;353:422–423
  36. Bates DW, Leape LL, Cullen DJ, et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311–1316
  37. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

 Supported by research grant AG14472 from the National Institute on Aging, Bethesda, Maryland. The contents are solely the responsibility of the authors and do not necessarily reflect the official views of the National Institute on Aging.

PII: S0002-9343(00)00451-4

The American Journal of Medicine
Volume 109, Issue 2 , Pages 87-94 , 1 August 2000