Polypharmacy in nursing home residents in the United States: Results of the 2004 National Nursing Home Survey

Background: Despite the need for and benefits of medications, polypharmacy (defined here as concurrent use of ≥9 medications) in nursing home residents is a concern. As the number of medications taken increases, so does the risk for adverse events. Monitoring polypharmacy in this population is important and can improve the quality of nursing home care.Objectives: The aims of this article were to estimate the use of polypharmacy in residents of nursing homes in the United States, to examine the associations between select resident and facility characteristics and polypharmacy, and to determine the leading therapeutic subclasses included in the polypharmacy received by these nursing home residents.Methods: This was a retrospective, cross-sectional study of a nationally representative sample of US nursing home residents in 2004; the outcome was use of polypharmacy. The 2004 National Nursing Home Survey was used to collect medication data and other resident and facility information. Resident characteristics included age, sex, race, primary payment source, number of comorbidities, number of activities of daily living (ADLs) for which the resident required assistance, and length of stay (LOS) since admission. Facility characteristics included ownership and size (number of beds).Results: Of 13,507 nursing home residents who received care, 13,403 had valid responses for all 9 independent variables in the analyses. The prevalence of polypharmacy among nursing home residents in 2004 was ~40%. A multiple regression model controlling for resident and facility factors revealed that the odds of receiving polypharmacy were higher for residents who were female (odds ratio [OR] = 1.10; 95% CI, 1.00–1.20), were white, had Medicaid as a primary payer, had >3 comorbidities (OR = 1.57–5.18; 95% CI, 1.36–6.15), needed assistance with <4 ADLs, had an LOS since admission of 3 to <6 months (OR = 1.25; 95% CI, 1.04–1.50), and received care in a small, not- for-profit facility (data not shown for reference levels [OR = 1.00]). The most frequently reported medications for residents who received polypharmacy included gastrointestinal agents (laxatives, 47.5%; agents for acid/peptic disorders, 43.3%), drugs that affect the central nervous system (antidepressants, 46.3%; antipsychotics or antimanics, 25.9%), and pain relievers (nonnarcotic analgesics, 43.6%; antipyretics, 41.2%; antiarthritics, 31.2%).Conclusions: Despite awareness of polypharmacy and its potential consequences in older patients, results of our analysis suggest that polypharmacy remains widespread in US nursing homes. Although complex medication regimens are often necessary for nursing home residents, monitoring polypharmacy and its consequences may improve the quality of nursing home care and reduce unnecessary health care spending related to adverse events.     

Determinants of antidepressant medication prescribing in elderly residents of aged care homes in Australia: A retrospective study

Background: Depression is underrecognized and poorly treated among older people living in aged care homes worldwide. Depression has been associated with higher rates of recurrence, disability, and death in older people.Objectives: The primary objective of this study was to assess the determinants of antidepressant medication prescribing among older people living in aged care homes in Australia. A further objective was to investigate the anti-depressant medications in common use, doses of antidepressants, and concurrent pharmacotherapy among people receiving antidepressants.Methods: A random sample of 500 deidentified medication review reports was extracted from a database containing >165,000 Residential Medication Management Review reports. Residents' demographic and clinical characteristics, medical diagnoses, and prescribed medications were systematically extracted from these reports. Logistic regression models were used to determine factors associated with the prescribing of any antidepressant, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and “other” antidepressants (eg, mianserin, mirtazapine, venlafaxine).Results: The mean (SD) age of the residents was 84.0 (9.0) years. Seventy-five percent were female. The prevalence of antidepressant prescribing among these aged care home residents was 33.0%. SSRIs were more commonly prescribed than TCAs, monoamine oxidase inhibitors, and other antidepressants. Antidepressants were more likely to be prescribed in people treated for dementia with mood disorder (odds ratio [OR] = 9.70; 95% CI, 5.26–17.88), depression (OR = 13.28; 95% CI, 6.44–27.36), and Parkinson's disease (OR = 3.56; 95% CI, 1.37–9.23). SSRI prescribing was associated with dementia with mood disorder (OR = 5.85; 95% CI, 3.19–10.72) and depression (OR = 6.44; 95% CI, 3.38–12.26). TCA prescribing was associated with depression (OR = 2.95; 95% CI, 1.18–7.35) and concurrent benzodiazepine use (OR = 2.43; 95% CI, 1.03–5.72). Other antidepressant prescribing was associated with dementia with mood disorder (OR = 6.53; 95% CI, 3.15–13.50) and depression (OR = 5.00; 95% CI, 2.23–11.19).Conclusions: There was preferential prescribing of SSRI antidepressants among these older aged care home residents with depression. Cognitive impairment alone was not significantly associated with antidepressant prescribing; however, these aged care home residents with dementia and mood disorders had an increased likelihood of being treated with antidepressants. The prescribing of TCAs was significantly associated with concurrent benzodiazepine use.     

Nursing student medication errors involving tubing and catheters: A descriptive study

This retrospective case study examined reports (N = 27) of medication errors made by nursing students involving tubing and catheter misconnections. Characteristics of misconnection errors included attributes of events recorded on MEDMARX^® error reports of the United States Pharmacopeia. Two near miss errors or Category B errors (medication error occurred, did not reach patient) were identified, with 21 Category C medication errors (occurred, with no resulting patient harm), and four Category D errors (need for increased patient monitoring, no patient harm) reported. Reported intravenous tubing errors were more frequent than other type of tubing errors and problems with clamps were present in 12 error reports. Registered nurses discovered most of the errors; some were implicated in the mistakes along with the students.     

Doctor-Related Medication Safety Incidents on a Specialist Palliative Medicine Inpatient Unit: A Retrospective Analysis of Three Years of Voluntary Reporting

Patients receiving palliative care and those at the end of life are known to be susceptible to medical errors. Errors related to medications are the most avoidable cause of patient harm. This retrospective study examined reported anonymized medication safety incidents, related to physician errors, assessed by the risk committee in a specialist palliative care unit over a 3-year time period. The aim of the study was to describe medication errors, with specific attention paid to what type of errors occurred and when these errors happened. Of the 218 reported medication safety incidents 28% (n = 62) were related to doctor prescribing. The data showed that there was a wide variation per year in the numbers of reported medication safety incidents. Medication prescribing errors were the most common error, followed by medication omissions. Medication safety incidents are at least in part dependent on staff reporting. Fostering a culture of openness that is blame free is crucial to medication error reporting. Formal reporting may help to increase patient safety and forms an essential element in the clinical governance and risk management of an institution.     

An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program.

Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.     

Enhancing patient safety: The importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students

Reid‐Searl K, Moxham L, Happell B. International Journal of Nursing Practice 2010; 16 : 225–232
Enhancing patient safety: The importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students Medication errors have been the focus of considerable research attention in nursing; however, the extent to which nursing students might contribute to errors has not been researched. Using a grounded theory approach, in‐depth semi‐structured interviews were conducted with undergraduate nursing students based in a university in Queensland to explore their experiences of administering medication in the clinical setting. Almost a third of the participants reported making an actual medication error or a near miss. Where medication errors occurred, participants described not receiving direct and appropriate supervision by a registered nurse. Medication errors by nursing students have the potential to impact significantly on patient safety, quality of health care, and on nursing students' perceptions of their professional competence. Ensuring direct supervision is provided at all times must become an urgent priority for undergraduate nursing education.     

The Effect of Implementing Bar-Code Medication Administration in an Emergency Department on Medication Administration Errors and Nursing Satisfaction

IntroductionBar-code medication administration has been shown to reduce medication errors in inpatient settings with limited studies on its use in emergency departments. In addition, no studies have evaluated nursing satisfaction with implementing bar-code medication administration in an emergency department. This study was designed to determine the impact of implementing bar-code medication administration in an emergency department on medication errors and nursing satisfaction.MethodsThis is a before-and-after study, with no control group, of a bar-code medication administration intervention conducted in a community hospital emergency department. Direct observation was used to compare medication error rates before and 3 months after implementing bar-code medication administration. The Medication Administration System—Nurses Assessment of Satisfaction survey was used to assess the impact on nursing satisfaction before and 1 month after bar-code medication administration implementation.ResultsA total of 676 medication administrations were observed in the period before bar-code medication administration implementation and 656 after. The medication administration error rate preimplementation was 2.96% with “wrong dose” errors being the most common. After bar-code medication administration implementation, the medication administration error rate fell to 0.76%, a relative reduction of 74.2% (Fisher exact P < 0.01). The average (SD) Medication Administration System—Nurses Assessment of Satisfaction score preimplementation was 2.60 (0.75) and improved to 2.29 (0.66) (t = 2.00, P = 0.05) 1 month post implementation.DiscussionImplementing bar-code medication administration in a community emergency department was associated with a decrease in medication administration errors and an improvement in Medication Administration System—Nurses Assessment of Satisfaction scores. The results of this study suggest a benefit of bar-code medication administration in reducing medication administration errors and improved nursing satisfaction in the emergency department.     

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative,unit-based project

Aim To implement the sterile cockpit principle to decrease interruptions and distractions during high volume medication administration and reduce the number of medication errors. Background While some studies have described the importance of reducing interruptions as a tactic to reduce medication errors, work is needed to assess the impact on patient outcomes. Methods Data regarding the type and frequency of distractions were collected during the first 11 weeks of implementation. Medication error rates were tracked 1 year before and after 1 year implementation. Results Simple regression analysis showed a decrease in the mean number of distractions, (β = −0.193, P = 0.02) over time. The medication error rate decreased by 42.78% (P = 0.04) after implementation of the sterile cockpit principle. Conclusions The use of crew resource management techniques, including the sterile cockpit principle, applied to medication administration has a significant impact on patient safety. Implications for nursing management Applying the sterile cockpit principle to inpatient medical units is a feasible approach to reduce the number of distractions during the administration of medication, thus, reducing the likelihood of medication error. ‘Do Not Disturb’ signs and vests are inexpensive, simple interventions that can be used as reminders to decrease distractions.     

Medication error encouragement training: A quasi-experimental study

BackgroundMedication errors are the most common clinical errors in healthcare practice and can lead to serious consequences. Medication error encouragement training (MEET) brings students face-to-face with potential errors in the medication process, in a safe environment where they are encouraged to understand both the error and the context in which it occurred.ObjectivesThe study aimed to examine the effects of a MEET intervention on medication safety confidence among nursing undergraduates.DesignThis was a quasi-experimental study with a nonequivalent control group design.ParticipantsOur sample was recruited from the nursing education department of a university, with 47 participants randomly assigned to the experimental group, and 50 to the control group.MethodsBoth groups received theoretical training, followed by applied training. The experimental group received the MEET intervention developed specifically for this study, while the control group received traditional error avoidance training. Participants' medication administration confidence was measured pre- and post-intervention.ResultsFollowing training, the experimental group's confidence was significantly higher than that of the control group. With regard to individual medication administration procedures, the experimental groups' medication safety confidence increased significantly after training compared to the control group in patient identification, drug information confirmation, and drug preparation.ConclusionsIntroducing MEET into nursing curricula could reduce medication errors and related complications in healthcare institutions. Further studies are needed to investigate the long-term effects of MEET interventions, as well as the generalizability of our findings.     

Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany

Objective: The aim of this study was to quantify and classify errors associated with the repackaging of residents' medications in long-term care facilities in Germany.Methods: This was a prospective 8-week study conducted in 3 long-term care facilities. Pill organizers, each of which contained all repackaged solid oral dosage forms of long-term medications for a particular resident for an entire day, were inspected and checked against residents' medication sheets by the investigator-pharmacist. On agreement between the pharmacist and the registered nurse responsible for residents' medications, all errors were rectified before medications were administered. The primary study measure was the overall rate of incorrectly repackaged medications relative to all repackaged medications. Secondary measures were the proportion of all pill organizers with medication errors and the proportion of residents who would have been affected by these errors. Errors were categorized by type as follows: wrong time of administration, wrong dose, wrong medication, omission of a medication, extra dose, incorrect halving of tablets, and damaged medication.Results: One hundred ninety-six residents were included in the study, representing 8798 daily pill organizers and 48,512 inspected medications. Residents received a mean of 5.4 solid oral dosage forms of long-term medications per day. Six hundred forty-five errors were detected, for an error rate of 1.3%; the errors involved 7.3% of daily pill organizers and 53.0% of residents. The largest proportion of errors involved incorrect halving of tablets (49.1%), followed by omission of a medication (22.0%), extra dose (9.8%), wrong time of administration (8.4%), damaged medication (6.4%), wrong dose (4.2%), and wrong medication (0.2%). These results may underestimate true rates of repackaging errors across long-term care facilities in Germany, as the conditions in the 3 facilities in this study were near-optimal in terms of the environment, process, and quality of repackaging.Conclusions: Among 48,512 medications inspected over 8 weeks in 3 German long-term care facilities, the rate of repackaging errors was 1.3%, involving 7.3% of daily pill organizers and the medications of 53.00% of residents. The largest proportion of errors involved incorrect halving of tablets.     

护士发生给药错误的特点及原因分析

目的分析护士给药错误发生的特点和原因,探讨如何预防给药错误的发生。方法回顾性分析某三级甲等医院2010年至2012年自愿非惩罚报告系统中上报的给药错误137例,分析护士给药错误的类别、特点及原因。结果给药错误主要发生在综合科室占31.39%,外科占24.82%;患者身份识别错误、药物遗漏、给药技术性错误是给药错误的主要类别;发生给药错误的药物种类,占前2位的分别是抗生素和心血管系统用药;在发生给药错误的原因中,操作过程中没有认真执行查对制度占48.91%。结论护理管理者应根据给药错误的特点制订相应的管理措施,加强护士药物知识的培训,严格执行查对制度,降低给药错误的发生。     

Reducing medication errors: Teaching strategies that increase nursing students' awareness of medication errors and their prevention

Medication errors are a patient safety and quality of care issue. There is evidence to suggest many undergraduate nursing curricula do not adequately educate students about the factors that contribute to medication errors and possible strategies to prevent them. We designed and developed a suite of teaching strategies that raise students' awareness of medication error producing situations and their prevention.     

Adverse outcomes associated with inappropriate drug use in nursing homes

BACKGROUND: Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents. OBJECTIVE: To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome. METHODS: A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data. RESULTS: A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1.139, 95% CI 1.105 to 1.173) significantly increased the likelihood of receiving an inappropriate drug, while having a diagnosis of "dementia" (OR 0.748, 95% CI 0.565 to 0.991) decreased the likelihood. Inappropriate medication use increased the likelihood of experiencing at least one adverse health outcome more than twofold (OR 2.34, 95% CI 1.61 to 3.40). Propoxyphene use alone was significantly associated with the occurrence of an adverse health outcome (OR 2.39, 95% CI 1.54 to 3.71). CONCLUSIONS: Inappropriate drug use was common in our study cohort. Inappropriate use of medication in the elderly, particularly propoxyphene, is associated with a higher risk of adverse health outcomes.     

Interventions to improve suboptimal prescribing in nursing homes: A narrative review

Background: Appropriate medication prescribing for nursing home residents remains a challenge. Objective: The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes.Methods: The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents.Results: Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in ≥1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions.Conclusions: Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature.     

Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies

Background: Medication discrepancies are unintended differences between medication regimens (ie, between a patient's home regimen and medications prescribed on admission to the hospital).Objective: The goal of this study was to describe the incidence, drug classes, and probable importance of hospital admission medication discrepancies and discharge regimen differences, and to determine whether factors such as age and specific hospital services were associated with greater frequency of medication discrepancies and differences.Methods: This was a retrospective cohort study of a random sample of adult patients admitted to the general medicine, cardiology, or general surgery services of a tertiary care academic teaching hospital between July 1, 2006, and August 31, 2006. A chart review was performed to collect the following information: patient demographic characteristics, comorbid conditions, number of preadmission medications, discrepant medications identified by the hospital's reconciliation process, reasons for the discrepancies, and discharge medications that differed from the home regimen. Potentially high-risk discrepancies and differences were identified by determining if the medications were included on either the Institute for Safe Medication Practices high-alert list or the North Carolina Narrow Therapeutic Index list. Univariate and multivariate logistic regression analyses were used to identify factors associated with medication discrepancies and differences.Results: Of the 205 patients (mean age, 59.9 years; 116 men, 89 women; 60% white) included in the study, 27 did not have any medications recorded on admission. Of the 178 patients who did have medications listed, 41 had ≥1 discrepancy identified by the reconciliation process on admission (23%; 95% CI, 17–29); 19% (95% CI, 11–31) of these medications were considered to be potentially high risk. In the multivariate logistic regression model, age (odds ratio [OR] per 5-year increase = 1.16; 95% CI, 1.01–1.33; P = 0.035), presence of high-risk medications on admission (OR = 76.68; 95% CI, 9.13–643.76; P < 0.001), and general surgery service (OR = 3.31; 95% CI, 1.40–7.87; P < 0.007) were associated with a higher proportion of patients with discrepancies on admission. At discharge, 196 patients (96% [95% CI, 93<98]) had ≥1 medication change from their home regimen, with 1102 total differences for 205 patients. Less than half (44% [95% CI, 37–51]) of these patients were explicitly alerted at discharge to new medications or dose changes; 12% (95% CI, 7–18) were given written instructions to stop taking discontinued home medications. Cardiovascular drugs were the most frequent class involved at both admission (31%) and discharge (27%) in medication discrepancies or differences.Conclusions: Medication discrepancies on admission and medication differences at discharge were prevalent for adult patients admitted to the general medicine, cardiology, and general surgery services in this academic teaching hospital. Medication reconciliation processes have a high potential to identify clinically important discrepancies for all patients.