Medication Errors in Nursing Homes - Part 1

Background

- 800,000 preventable adverse drug reactions (ADEs) each year*

- most are serious, life threatening or fatal

- half are preventable

*Gurwitz et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med 2000; 109(2):87-94

Why so many? America is living longer and medications are the mainstay of treatment for chronically ill residents. Most medication orders are made by phone and often among multiple providers with limited knowledge of the resident (cross-cover physicians, Extenders, etc). Adjustments are often made without the current medication list and based on incomplete or inaccurate information. Miscommunication results in unnecessary medications, duplicative treatment and inappropriate dosing.

ADE Prevention Safe medication oversight is coordinated between the physicians (prescribing), pharmacies (dispensing), consultant pharmacists and nursing facilities (administration and monitoring). Most ADEs occur at the monitoring stage. Revised guidelines for F-Tag 329 (Unnecessary Medications) and F-Tag 428 (Medication Regimen Review) emphasize multidisciplinary accountability. While they make a positive impact on dispensing and administration, the physician role in monitoring is still underutilized and facilities may not have the systems to readily change this. EMR (electronic medical record) software has the potential to play a pivotal role in reducing medication errors.

In spite of the guidelines and the best intentions of all, the following scenario is all too familiar:

- Day 1 Physician (PCP) visit diagnosis depression and prescribes antidepressant A.

- Day 2 Facility weekend staff notes depression, calls on-call physician. Medication list is unavailable and antidepressant B is added.

- Day 30 Consulting pharmacist reviews duplicate medication. Recommendation left for staff to follow up with PCP.

- Day 37 Recommendation given to PCP staff. PCP is aware but will not change the medications without reviewing the patient.

- Day 50 PCP visit discontinues antidepressant B.

The scenario above was preventable if the medication list had been available to the on-call physician.

New Opportunities Greater physician use of CPOE (e-prescribing) and electronic medical record technology in nursing homes promises new opportunities for medication error reduction.