SEPT. 18, 2000

National Notes
Some Nursing Homes Plagued by Medication Injuries

Injuries related to medication errors are common in nursing homes, according to a study by researchers at the University of Massachusetts Medical School, Meyers Primary Care Institute. In fact, more than half of the 546 medicate-related injuries that were identified in 18 community nursing homes were preventable.

Of the total adverse drug events identified in the study, one was fatal, 6% were life-threatening, 38% were serious, and 56% were significant. The study also identified 188 potential adverse drug events or "near misses," 80% of which were associated with the use of the blood thinner warfarin. Psychoactive drugs (antipsychotics, antidepressants, sedatives, and hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events.

The most frequent causes of preventable adverse drug events were associated with drug orders by health care providers (47%) and with failure of caregivers to adequately monitor residents (49%). Among the ordering errors, incorrect dosage was most common, followed by harmful drug interactions and inappropriate drug choices. Most common among monitoring errors was inadequate lab monitoring of drug therapies and slow or no response to symptoms or signs of drug toxicity.

"We’re not saying people shouldn’t be on these drugs," says Jerry Gurwitz, M.D. "We’re saying that sometimes providers are not monitoring residents appropriately and are missing signals that patients are experiencing adverse effects from drugs. Clearly this offers an incredible opportunity to improve meaningfully on the health of a very vulnerable patient population."