Reducing Medication Errors in Nursing Homes

by Jacqueline Vance, RNC,
AMDA's Director of Clinical Affairs

There are myriad situations that may lead to medication errors. For example, a newly admitted resident arrives from an acute care hospital late in the day with only a transfer summary dictated by an orthopedic surgeon. The attending physician, who is new to the patient, is called to approve the transfer orders. He returns the call after the admitting nurse has left and is given incomplete information about the patient from an agency nurse. It may be that an inadequately trained ward clerk is assigned to transcribe the handwritten admission orders, to be verified by a harried nurse in a hurry to go home. Medications might be delivered to the facility from the pharmacy, but the contents of the delivery bag are not verified.

The more medications a patient is taking, the greater the chance of interactions, and the greater the risk of errors. Medicaid data for one state showed that during a 30-day period, 68% of long-term care patients had received 9 or more prescription drugs, and 32% had received 20 or more prescription drugs.

Although only a small number of medication errors actually cause adverse drug events (ADEs), as many as 50% of ADEs are caused by errors. Their consequences--falls and fractures as well as greatly increased costs (see boxes at right)--can't be ignored.

Types of Errors

The majority of prescribing errors involve lack of assessment, lack of monitoring for efficacy, lack of reassessment for continuous need, lack of monitoring for adverse drug reactions (ADRs), lack of recognition of ADRs, and attributing symptoms of ADRs to other causes (see box at right). Inadequacies in physician education or training in principles of geriatric assessment and pharmacology may lead to such problems.

Physician attitudes can also play a role in prescribing errors. For example, some physicians refuse to consider non-pharmacologic interventions to treat certain conditions. Other physicians may refuse to consider pharmacy consultants' recommendations for medication changes when there may be a high risk of drug interaction with a current medication regime.

In addition, physicians face many pressures while practicing in long-term care--for instance, having to see many patients in one facility while trying to squeeze in emergency calls and a busy office practice. Low reimbursement for nursing home visits despite high demands can be frustrating to many physicians. Coupled with that is the usual burdensome filling out of dozens of forms and progress notes to fulfill documentation requirements. There is also the fear of regulatory consequences and having to deal with conflicting and sometimes unreasonable and poorly understood regulations.

Finally, there is a dearth of general management as well as medication-specific information systems that can facilitate prescribing, administration, and monitoring of medications. When there are no established processes for obtaining patient-specific information from other facilities or practitioners, for proper assessment and cause-finding, or for communication among various practitioners and team members,medication errors are bound to occur.

Ongoing Problem

The response to the problem of medication errors is not new, but a continuation of a response that started years ago. In 1974, nursing facilities became the only health care institutions required to obtain the services of a consultant pharmacist, who was charged with medication regimen reviews that physicians were required to respond to. Because there was continuing evidence of problems, under OBRA '87, additional regulations were developed that attempt to "micro-manage" the process of prescribing. Further regulations were added in the '90s.

The regulations also provided surveyors with an investigative protocol to review the potential for ADRs. Investigators are instructed to ask specific questions, including: Was the risk for ADRs identified? Did the benefit of a drug outweigh the risk? Is the drug in use a valid therapeutic intervention? Was the ADR identified, was it reported, and what was the response?

Physicians and facilities must be prepared to not only answer these questions, but also show documented evidence that supports their answers. According to guidance to surveyors in the State Operations Manual (SOM; Appendix Q), failure to protect a resident from undue medication consequences and/or failure to provide medications as prescribed leads to a finding of immediate jeopardy.

The OBRA regulations did succeed in reducing the use of inappropriate antipsychotic medications in nursing facilities. There is also some evidence to suggest that errors in dispensing and administration of medications are lower in long-term care facilities than in hospitals. But there is no evidence to date that the regulations had any impact on reduction of medications errors related to prescribing and monitoring.

Realizing that regulations are not an appropriate way to improve care, and responding to members' needs, AMDA formed the Multidisciplinary Medication Management workgroup in collaboration with the American Society of Consultant Pharmacists (ASCP). The goal of Multidisciplinary Medication Management is to develop strategies to help physicians and other care team members in LTC to improve medication management. These strategies include information, education, and development of tools for improvement.

Strategies for Improvement

Physicians are key in making progress towards reducing medication errors; therefore, physicians must be open to education and other interventions that would lead to change in clinical practice. In addition, medical directors are responsible for ensuring that there are processes in place for assessment of residents by attending physicians. Standardized assessment tools such as the Mini-Mental Status exam, Geriatric Depression Scale, and pain assessments, for example, are important for obtaining accurate information about the resident's physical, mental and functional status.

By the same token, physicians need to have knowledge of information related to objective and timely drug information, geriatric practice and pharmacological principles, federal and local regulations, drug costs, and use of information technology to obtain patient and drug data at the point of prescribing.To ensure patient safety, physicians should document the risk-benefit ratio for drugs with a high ADR potential, and consultant pharmacists should focus on these drugs and notify physicians in a timely way, particularly with new prescriptions.

Nursing assessment skills are also critical. They need to be aware of the common geriatric syndromes associated with an adverse drug event and notify the physician when one occurs.

It is also important to note that ADRs may mimic common geriatric syndromes. Thus, practitioners need to avoid the pitfall of mistaking symptoms of ADRs for another condition, inadvertently setting in motion a cascade of treating symptoms with another medication and causing even more ADRs.

Although such strategies are not always easy to implement, the members of the Multidisciplinary Medication Management workgroup are convinced that when applied, these strategies can significantly improve the prescribing and monitoring of medications; cut overuse, underuse, and inappropriate use of medications; and significantly reduce the incidence of medication errors and adverse drug reactions in long-term care. Moreover, the education, information, and process tools gained by physicians in long-term care by these efforts will contribute to the improvement of medical care in all other settings in which long-term care physicians practice.

This article originally appeared in Caring for the Ages, April 2003; Vol. 4 No. 4, p. 49-51. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission. The opinions expressed by the authors are their own and not necessarily those of AMDA or of Elsevier.

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