Repeat medication errors in nursing homes: Contributing factors and their association with patient harm

Background: Medication errors are highly prevalent in long-term care facilities and are responsible for preventable injury. Repeat medication errors, or identical events occurring multiple times in the same patient, may be particularly preventable.Objectives: This study assessed the factors that contribute to repeat medication errors and the association between repeat medication errors and patient harm.Methods: In this cross-sectional analysis, medication error reports submitted by licensed nursing homes to North Carolina's Medication Error Quality Initiative-Individual Error Web-based incident reporting system were analyzed for fiscal years 2006–2008. When reporting errors, the sites were asked whether the event was identically repeated within the same patient. Repeat medication errors were defined as identical events in terms of patient characteristics, drug involved, error type, potential cause, phase of the medication care process, and personnel involved. Repeat errors were compared with nonrepeat errors. Multivariate logistic regression was used to explore whether certain patient or error characteristics were related to a higher likelihood of repeat errors, and a similar analysis was used to explore whether repeat errors were related to patient harm.Results: Of the total 15,037 errors reported by 294 unique nursing homes, 5615 (37.3%) were repeated one or more times. Among the repeat errors, the associated event within each error was repeated a mean (SD) of 10.7 (14.3) times. Wrong dosage (65.1% [3654/5615]) and wrong administration (10.2% [571/5615]) were the most frequent repeated events. In multivariate analysis, repeat errors occurred less frequently among younger residents (aged <75 years) than among older residents (aged ≥75 years) (odds ratio [OR] = 0.85; 95% CI, 0.79–0.93) and among residents able to direct their own care compared with cognitively impaired residents (OR = 0.87; 95% CI, 0.81–0.95). Patient harm was reported in only 1.2% (68/5615) of repeat errors and 0.6% (55/9422) of non-repeat errors. A multivariate analysis of patient harm found that repeat errors were more likely to be harmful than were nonrepeat errors (OR = 2.11; 95% CI, 1.43–3.11).Conclusions: Repeat medication errors in nursing homes are a common occurrence and have greater odds of being associated with harm than do nonrepeat errors. Future patient-safety research should focus on factors related to repeat errors.     

Prochlorperazine tablets repackaged into dose administration aids: can the patient be assured of quality?

Background and objective: Patients are increasingly requiring their medications to be repackaged into dose administration aids because of the positive outcomes associated with reduction in medication related hospitalization and adverse effects due to improved medicines management. Since the stability of these repackaged medications is not the responsibility of manufacturer, it is important that drug substances with potential stability issues be identified. Thus the objective of this study was to evaluate the stability of prochlorperazine, a light sensitive drug repackaged into dose administration aids (DAAs), in order to provide guidelines to the pharmacist and advice to the patient on appropriate storage. Methods: Prochlorperazine tablets were stored repackaged in DAAs and in their original packaging for 8 weeks at ambient (25 ± 1 °C; 60 ± 1·5% RH), accelerated (40 ± 1 °C; 75 ± 1·5% RH) and in‐use conditions encountered in situ both in a pharmacy and the patients’ home. They were assessed for both chemical (using a validated HPLC method) and physical stability according to British Pharmacopoeial (BP) standards. In addition, photostability testing was undertaken under ICH conditions. Results and discussion: Chemical and physical stability was confirmed to be within BP Limits.
There were, however, noticeable organoleptic changes in the tablets stored under in‐use conditions with a progressive grey discolouration over the 8 weeks, starting in week 2. Conclusion: Despite the confirmation of physical and chemical stability within BP limits, the discoloration and the potential for photodegradants to cause adverse effects in patients must lead us to draw the conclusion that the quality of this medication has been compromised. Pharmacists thus need to take this into account in repackaging and storage of prochlorperazine in DAAs and advise patients to store their DAA protected from light, heat and humidity.     

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: A pilot quality improvement project

Background: Patients being transferred to a nursing home (NH) after an acute hospitalization are subject to adverse effects, including medication errors, related to poor coordination of care across settings.Objective: The goal of this study was to develop, implement, and evaluate the impact of a pilot intervention to improve patient safety by reducing delays in administration and omission of medications among patients discharged from the hospital to the NH.Methods: An expedited discharge protocol was developed in collaboration with hospital physician residents, hospital discharge planners, and NH staff (administrators, directors of nursing services, and licensed nurses). The intervention included education of the involved health care professionals and implementation of the expedited protocol to ensure that medication orders were transmitted to the NH-contracted pharmacy before patients' arrival at the NH. The intervention protocol was compared with a standard discharge protocol among patients aged ≥65 years being discharged from 2 university-affiliated hospitals to a single proprietary NH. The primary outcomes were the time between arrival at the NH and administration of first dose of an ordered medication; the number of omitted medications; the proportion of patients experiencing medication omissions; and the proportion of patients with omitted medications that had a low, medium, and high potential for negative consequences.Results: The study involved 10 patients discharged from each of the 2 hospitals and transferred to the NH. Although several components of the intervention were successfully implemented, none of the medication orders were transmitted to the NH-ccontracted pharmacy before patients' arrival at the NH. All 17 patients with medications ordered to be administered in the evening had ≥1 dose of a medication omitted after their arrival at the NH. The mean (SD) delay from arrival at the NH to administration of the first dose of an ordered medication was 12.55 (7.45) hours. The mean number of doses of different medications omitted per patient was 3.4 (2.60). Sixty-seven doses of medications were omitted; 53 of these omissions involved only 1 dose of a medication. Thirty-three percent of omitted doses involved medications with the highest potential for resulting in a negative consequence.Conclusions: The intervention to improve patient safety by reducing medication delays for patients making the transition from the hospital to the NH was not successfully implemented, as medication orders were not transmitted to the NH-contracted pharmacies before patients' arrival at the NH. All patients making the transition from hospital to NH experienced a >12-hour delay in medication administration, and the mean number of missed doses of medications was >3. There is a need for further exploration of the reasons for and possible solutions to delays in medication administration during the transition to the NH, as well as of the impact of such delays on patient outcomes, including adverse drug events, emergency department visits, and rehospitalizations.     

Quality of medication records and use of pharmacy resources in community residential care facilities

BACKGROUND: In community residential care (CRC) facilities, medication administration is often performed by unlicensed personnel with minimal knowledge in medication use. Medication management is one of the top 3 quality-of-care issues facing these facilities. OBJECTIVE: To examine the type of medication assistance residents received, determine the proportion of facilities that used pharmacy resources, and examine the quality of facility medication records in CRC facilities (eg, adult family homes, adult residential care, assisted living facilities). METHODS: Baseline in-person interviews were conducted with 349 residents and 299 facility providers in the Puget Sound region of Washington. Information was also obtained from facility medication records at enrollment and state databases. A pharmacist determined quality of the records using a standardized form. RESULTS: The average resident was a 78-year-old white female taking 7 drugs. Medication records that were computer generated were significantly less likely to have misspelled names of drugs and errors in or absence of dose, directions for use, and route of administration. Overall, 26.3% of facilities reported that a consultant pharmacist reviewed residents' medication lists, 52.0% reported the use of preprinted lists, and 75.6% received prepackaged medications from the pharmacy. Adult family homes, the smallest facility type, were the least likely to use pharmacy-related services. CONCLUSIONS: The quality of handwritten medication records was a concern in CRC facilities. These facilities may benefit from services offered by pharmacies that may enhance medication management, many of which were underutilized.     

Medication errors during medical emergencies in a large, tertiary care, academic medical center

Purpose

Evaluate the rate, type and severity of medication errors occurring during Medical Emergency Team (MET) care at a large, tertiary-care, academic medical center.

Methods

A prospective, observational evaluation of 50 patients that required MET care was conducted. Data on medication use were collected using a direct-observation method whereby an observer documented drug information such as drug, dose, frequency, rate of administration and administration technique. Subsequently, a team of three clinicians assessed rate, type and severity of medication errors using definitions consistent with United States Pharmacopeia MEDMARX system. Severity was assessed on a scale of minor, moderate and severe.

Results

One hundred eighty six doses were observed for 36 different medications. A total of 296 errors were identified; of these 196 errors (66%) were inappropriate aseptic technique. Of the remaining 100 errors, 46% were prescribing errors, 28% administration technique errors, 14% mislabeling errors, 10% drug preparation errors and 2% improper dose prescribing. Examples included: (1) prescribing errors, (2) administering wrong doses, (3) mislabeling, and (4) wrong administration technique such as not flushing intravenous medication through intravenous access. The rate of medication administration errors was 1.6 errors/dose including aseptic technique and 0.5 errors/dose excluding aseptic technique. A notable portion (14%) of errors was considered at least moderate in severity.

Conclusions

One out of 2 doses was administered in error after errors of using inappropriate aseptic technique were excluded. There is a need for education and systematic changes to prevent medication errors during medical emergencies as an effort to avoid harm.     

How reliable are patient-completed medication reconciliation forms compared with pharmacy lists?

Objectives

Medication reconciliation is a Joint Commission for the Accreditation of Healthcare Organizations requirement to reduce medication errors. This study evaluated the reliability of patient-completed medication reconciliation forms (MRs) compared with pharmacy-generated lists and determined if there was a difference in concordance when patients completed the forms from memory compared with when they brought a separate list or pill bottles.

Methods

We prospectively enrolled patients with completed MRs. Research assistants contacted the patient's pharmacy to determine medications filled in the prior 3 months, which was compared with the MR. Discrepancies and the method by which the patient completed the MR (memory, list, or pill bottles) were recorded.

Results

Three hundred fifteen patients were enrolled. Thirty-three percent made errors of omission (reported by pharmacy, but not on MR), 12.7% made errors of addition (reported on MR, but not by pharmacy), 18.1% made both types of errors, and 36.3% made no errors. Patients with errors were on 5.6 medications compared with 3.6 medications for those without errors (P < .0001). Those completing the MR from a list made 2.3 errors compared with 1.2 for those completing from memory and 1.8 for those completing from their pill bottles (P < .001). Of 390 medications omitted from patient lists, 16% were cardiac medications, 13% were neuropsychiatric agents, and 9.5% were narcotics.

Conclusions

Thirty-six percent of patients were able to provide a medication list that matched their pharmacy-prescribed drugs. More errors were noted from patients taking more medications and from those completing their MR from a separate list.     

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.     

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.     

Medication administration errors in adult patients in the ICU

OBJECTIVE: To quantify the incidence and specify the types of medication administration errors from a list of error-prone medications and to determine if patient harm resulted from these errors. DESIGN: An observational evaluation. SETTING: Five intensive care units (ICUs) in the United States. PATIENTS AND PARTICIPANTS: Eight hundred fifty-one patients who were at least 18 years of age and admitted to surgical, medical or mixed ICUs during a 3 month period were included. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A list of error-prone medications was adapted from the literature and evaluated for medication errors and patient harm. Of 5,744 observations in 851 patients, 187 (3.3%) medication administration errors were detected. the therapeutic classes most commonly associated with errors were vasoactive drugs 61 (32.6%) and sedative/analgesics 48 (25.7%). The most common type of error was wrong infusion rate with 71 (40.1%) errors. Twenty-one errors did not reach the patient and 159 reached the patient but did not result in harm, increased monitoring or intervention. Five errors required increased patient monitoring and two required intervention. None of the errors resulted in patient death. CONCLUSIONS: This multicenter evaluation found fewer medication administration errors than the published literature, possibly due to the varying observational techniques and pharmacist involvement. Lorazepam and wrong infusion rates are associated with errors that occurred frequently, resulted in the greatest potential for harm and were common oversights in the system. These errors should be considered potential areas for betterment in the medication use process to improve patient safety.     

Concerns and beliefs about medicines and inappropriate medications: An internet-based survey on risk factors for self-reported adverse drug events among older adults

Background: Adverse drug events (ADEs), which can be especially problematic in older adults, often can be prevented by detecting potential risk factors. Sociopsychological factors such as concerns and beliefs about medicines (patients' anxieties about the harmful effects of prescribed medications) may also be risk factors related to self-reported ADEs, even when considering clinical variables such as receiving an inappropriate medication.Objectives: This study was designed to quantify the use of inappropriate medications among older adult outpatients and to determine whether an association exists between the use of inappropriate medications, concerns and beliefs about medicines, and self-reported ADEs.Methods: This cross-sectional, Internet-based survey of Medicare beneficiaries was conducted in 2007. Harris Interactive®, a New York-based marketing research firm, invited participants from their online panel who were ≥65 years of age, residents of the United States, and enrolled in the Medicare health plan to participate in the survey. The updated Beers criteria and a modified version of the Assessing Care of Vulnerable Elders quality indicators were used to determine the appropriateness of medications. Respondents' concerns about their medicines were assessed using items from a validated scale such as “Having to take medicines worries me” and “I sometimes worry about the long-term effects of my medicines.” To establish self-reported ADEs, respondents were asked, “Did you see a doctor about any side effects, unwanted reactions, or other problems from medicines you were taking in the past year?”Results: Of the 1024 panelists who responded to the survey, 874 provided all of the information required for analysis. The respondents who were included in the analyses ranged in age from 65 to 94 years; 56.6% were female, 94.4% were white, and 20.3% self-reported an ADE. The frequency of patients receiving either an inappropriate medication or a medication that failed a quality indicator was 45.8%. Stronger concerns and beliefs about medicines (odds ratio [OR] = 1.57; 95% CI, 1.02–2.39; P = 0.04) and having more symptoms (OR = 2.26; 95% CI, 1.22–4.22; P = 0.01) were significantly related to self-reporting of ADEs, whereas receiving an inappropriate medication (OR = 1.03; 95% CI, 0.65–1.64) and the number of medications received (OR = 1.28; 95% CI, 0.52–3.13) were not.Conclusions: Stronger concerns and beliefs about medicines and having more symptoms were significantly related to self-reporting of ADEs. Receiving an inappropriate medication and the number of medicines received were not significantly related.     

Adverse effects of oral nonstimulant psychotropic medications in young children reported to a regional poison center

Background. Use of nonstimulant psychotropic medications other than antidepressants in young children is reported to be increasing. The patient safety ramifications of this remain unclear. Objectives. To evaluate the frequency of calls to a regional poison center reporting adverse drug effects and the level of medical attention required in young children who are receiving oral nonstimulant psychotropic medications. Materials and methods. A retrospective review of 544 267 consecutive human exposure poison center records between 2000 and 2008 was conducted for cases of young children given nonstimulant psychotropic medications with therapeutic intent. Results. A total of 597 cases met criteria for analysis. Drugs involved were 286 risperidone, 133 clonidine, 114 quetiapine, 37 aripiprazole, 43 olanzapine, 29 ziprasidone, and 5 buspirone; two or more were involved in 250 cases. Reasons for exposure included excess dose given unintentionally (61%), wrong medication unintentionally (12%), adverse effects with correct dose (11%), excess dose intentionally (0.6%), therapeutic error by health-care provider (0.5%), and unclear circumstances (15%). Moderate effects (such as dystonic reaction) occurred in 34 patients at their usual dose (53% of 64) and in 15 at unintentionally excessive doses (4% of 361). Emergency department evaluation of 22% of the children resulted in 5% of the total being admitted to a non-intensive care unit (ICU) bed and 2% of all admitted to an ICU bed. Conclusion. Dosing errors and adverse effects involving nonstimulant psychotropic medications are cause for concern in young children. Additional information about safety and optimal dosage of these medications is needed to guide appropriate use.     

Analysis of the North Carolina Long-Term Care Polypharmacy Initiative: A multiple-cohort approach using propensity-score matching for both evaluation and targeting

Background: The high cost and undesirable consequences of polypharmacy are well-recognized problems among elderly long-term care (LTC) residents. Despite the implementation of the 1987 Omnibus Budget Reconciliation Act, which requires pharmacist review of drug regimens in this setting, medical and drug costs for LTC residents have continued to increase.Objective: This study evaluates the North Carolina Long-Term Care Polypharmacy Initiative, a large-scale medication therapy management program (MTMP) that combined drug utilization review activities with drug regimen review techniques.Methods: This was a prospective records-based study that used a difference-in-difference model with both historical and nonintervention group controls. To ensure equivalence among subjects, propensity scoring was used to match study subjects from participating LTC facilities with comparison subjects from nonparticipating facilities. Residents with interventions were grouped for analysis by intervention type—retrospective only, prospective only, or dual type (residents with both prospective and retrospective interventions)—and by intervention stage—review, recommendation, and drug change—plus an all-inclusive “all types” grouping that aggregated groups by intervention type, for a total of 10 total cohorts.Results: In the overall population of 5255 study subjects identified, a US $21.63 per member per month drug-cost savings was observed. Although only 1 of 10 cohorts had a change in the number of drug fills, substantial reductions in 2 of 5 types of drug alerts were observed in all 10 cohorts. A reduction in the relative risk for hospitalization (0.84 [95% CI, 0.71–1.00]) was observed in the cohort of residents receiving a retrospective review.Conclusions: This Initiative suggests that an MTMP can be quickly launched in a large number of LTC facility residents to produce monetary drug-cost savings and improved health outcomes. Additionally, the evaluation of this program illustrates the utility of using propensity scoring techniques to target future intervention groups in a cost-effective manner.     

Descriptive epidemiology of infant ingestion calls to a regional poison control center

OBJECTIVE: This study was designed to describe the epidemiology of ingestions in infants 6 months of age or younger. METHODS: A retrospective chart review from a convenience sample of poison center cases in infants younger than 6 months of age from December 28, 2002, to December 28, 2003, was reviewed. RESULTS: A total of 358 cases were reviewed. Incorrectly measured dose, repeated dosing by different caregivers, incorrect dosing interval, and incorrect route accounted for 41% [95% CI, (36%, 46%)] of caregiver dosing misadventures. Ten cases (3%) were due to pharmacy error, and the wrong medication was given in 32 (9%) cases. The total therapeutic misadventure proportion was 53%. Eight percent were 10-fold dosing errors. Thirty-nine (11%) infants were evaluated in an emergency department and 9 (3%) infants were admitted to a health care facility. CONCLUSIONS: Therapeutic misadventures caused by dosing errors in infants younger than 6 months of age were prevalent. Most errors occurred with inaccurate measurement of the medication, repeated dosing by caregivers, incorrect dosing interval, and incorrect route. Healthcare providers could increase prevention of therapeutic misadventures by educating caregivers on proper administration of medications and by demonstrating the use of appropriate measuring devices.