Abstract
PURPOSE: Adverse drug events, especially those that may have been preventable, are
among the most serious concerns about medication use in nursing homes. We studied
the incidence and preventability of adverse drug events and potential adverse drug
events in nursing homes.
METHODS: We performed a cohort study of all long-term care residents of 18 community-based
nursing homes in Massachusetts during a 12-month observation period. Potential drug-related
incidents were detected by stimulated self-report by nursing home staff and by periodic
review of the records of nursing home residents by trained nurse and pharmacist investigators.
Each incident was classified by 2 independent physician-reviewers, using a structured
implicit review process, by whether or not it constituted an adverse drug event or
potential adverse drug event (those that may have caused harm, but did not because
of chance or because they were detected), by the severity of the event (significant,
serious, life-threatening, or fatal), and by whether it was preventable. Examples
of significant events included nonurticarial rashes, falls without associated fracture,
hemorrhage not requiring transfusion or hospitalization, and oversedation; examples
of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion
or hospitalization, and delirium.
RESULTS: During 28,839 nursing home resident-months of observation in the 18 participating
nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential
adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse
drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and
308 (56%) were significant. Overall, 51% of the adverse drug events were judged to
be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious
events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often
at the stages of ordering and monitoring; errors in transcription, dispensing, and
administration were less commonly identified. Psychoactive medications (antipsychotics,
antidepressants, and sedatives/hypnotics) and anticoagulants were the most common
medications associated with preventable adverse drug events. Neuropsychiatric events
were the most common types of preventable adverse drug events.
CONCLUSIONS: Adverse drug events are common and often preventable in nursing homes.
More serious adverse drug events are more likely to be preventable. Prevention strategies
should target the ordering and monitoring stages of pharmaceutical care.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The American Journal of MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
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.
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.
- Changes in antipyschotic drug use in nursing homes during implementation of the OBRA-87 regulations.JAMA. 1994; 271: 358-362
- Psychoactive medication use in intermediate-care facility residents.JAMA. 1988; 260: 3016-3020
- The appropriateness of oral fluoroquinolone prescribing in the long-term care setting.J Am Geriatr Soc. 1994; 42: 28-32
- Reducing the use of H2-receptor antagonists in the long-term care setting.J Am Geriatr Soc. 1992; 40: 359-364
- A study of antipsychotic drug use in nursing homes.Am J Public Health. 1980; 70: 485-491
- Nursing home resources and tranquilizer use among the institutionalized elderly.J Am Geriatr Soc. 1991; 39: 869-875
- Inappropriate medication prescribing in skilled-nursing facilities.Ann Intern Med. 1992; 117: 684-689
- Adverse events related to drugs and drug withdrawal in nursing home residents.J Am Geriatr Soc. 1993; 41: 1326-1332
- The epidemiology of adverse and unexpected events in the long-term care setting.J Am Geriatr Soc. 1994; 42: 33-38
- Incidence of adverse drug events and potential adverse drug events.JAMA. 1995; 274: 29-34
- Relationship between medication errors and adverse drug events.J Gen Intern Med. 1995; 10: 199-205
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.
- Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.JAMA. 1999; 282: 267-270
- Explicit criteria for determining inappropriate medication use in nursing home residents.Arch Intern Med. 1991; 151: 1825-1832
- Explicit criteria for determining potentially inappropriate medication use by the elderly.An update. Arch Intern Med. 1997; 157: 1531-1536
- Suboptimal medication use in the elderly. The tip of the iceberg.JAMA. 1994; 272: 316-317
Folli HL, Poole RI, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics. 1987;79:781–722.
- Preventable deaths.Ann Intern Med. 1998; 190: 582-589
- Studies of illness in the aged.JAMA. 1963; 185: 914-919
- Skilled nursing facility standards for certification and participation in Medicare and Medicaid programs.Fed Regist. 1974; 39: 2238
Rosner B. Fundamentals of Biostatistics 3rd ed. Boston, Mass: PWS-Kent; 1990.
Phillips DP, Christenfeld, N, Glynn LM. Increase in U.S. medication-error deaths between 1983 and 1993. Lancet. 1998;351:643–644, 1983.
- Nursing home care in the United States.N Engl J Med. 1982; 307: 883-889
- The impact of OBRA on medical practice within nursing facilities.J Am Geriatr Soc. 1992; 40: 958-963
- A randomized trial of a consultation service to reduce falls in nursing homes.JAMA. 1997; 278: 557-562
- A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes.N Engl J Med. 1992; 327: 168-173
- Reducing antipsychotic drug use in nursing homes. A controlled trial of provider education.Arch Intern Med. 1993; 153: 713-721
- Atrial fibrillation and stroke prevention with warfarin in the long-term care setting.Arch Intern Med. 1997; 157: 978-984
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.
- Continuous improvement as an ideal in health care.N Engl J Med. 1989; 320: 53-56
- Error in medicine.JAMA. 1994; 272: 1851-1857
- Systems analysis of adverse drug events.JAMA. 1995; 274: 35-43
- The uses of error.Lancet. 1999; 353: 422-423
- Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.JAMA. 1998; 280: 1311-1316
Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
Article Info
Publication History
Published online: August 16, 2004
Accepted:
April 3,
2000
Received in revised form:
April 3,
2000
Received:
September 14,
1999
Footnotes
☆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.
Identification
Copyright
© 2000 Excerpta Medica Inc. Published by Elsevier Inc. All rights reserved.
