Medication Errors and Adverse Drug Events in Nursing Homes: Problems, Causes, Regulations, and Proposed Solutions

Abstract

The Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System has focused national attention on quality of care and the prevalence of medical errors in the healthcare system. According to the report, medical errors are responsible for a large number of deaths and additional morbidity in healthcare facilities and increased cost to the healthcare system. 1 Kohn LT Corrigan JM Donaldson MS To Err is Human: Building a Safer Health System. The Institute of Medicine National Academy Press, Washington, DC1999 Google Scholar A large proportion of medical errors are medication-related. 2 Leape LL Brennan TA Laird N et al. The nature of adverse events in hospitalized patients: Results of the Harvard medical practice study II. N Engl J Med. 1991; 324: 377-384 Crossref PubMed Scopus (2855) Google Scholar Medication-related errors and other adverse drug reactions are known collectively as adverse drug events (ADEs), defined as “any injury resulting from the medical use of a drug.” 3 Bates DW Spell N Cullen DJ et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997; 277: 307-311 Crossref PubMed Google Scholar , 4 Gurwitz JH Field TS Avorn J et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000; 109: 87-94 Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar ADEs occur across the entire healthcare delivery system and are most common in older people, particularly those in hospitals and nursing homes. 5 Rothschild JN Bates DW Leape LL Preventable medical injuries in older patients. Arch Intern Med. 2000; 160: 2717-2728 Crossref PubMed Scopus (220) Google Scholar , 6 Gurwitz JH Sanchez-Cross T Eckler MA Matulis J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994; 42: 33-38 Crossref PubMed Scopus (74) Google Scholar ADEs are the adverse events most common in hospitalized patients 2 Leape LL Brennan TA Laird N et al. The nature of adverse events in hospitalized patients: Results of the Harvard medical practice study II. N Engl J Med. 1991; 324: 377-384 Crossref PubMed Scopus (2855) Google Scholar and the second most common adverse event in nursing home residents. 6 Gurwitz JH Sanchez-Cross T Eckler MA Matulis J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994; 42: 33-38 Crossref PubMed Scopus (74) Google Scholar In a report to Congress published in January 2000, 7 United States General Accounting Office. Adverse drug events. The magnitude of health risk is uncertain because of limited incidence data. Report to congressional requesters. GAO/HEHS-00–21. Washington, DC, January 2000. Google Scholar the United States General Accounting Office (GAO) reviewed available studies and concluded that the magnitude of health risk, as well as the cost, is uncertain because of limited incidence data and the difficulty inherent in recognition and identification of ADEs. However, studies reviewed in the report showed a rate of 0.56 ADEs per 100 patients admitted to hospitals in Colorado and Utah and 0.72 in New York. 8 Brennan TA Leape LL Laird NM et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard medical practice study I. New Engl J Med. 1991; 324: 370-376 Crossref PubMed Scopus (3435) Google Scholar , 9 Thomas EJ Studdert DM Burstin HR et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000; 38: 261-271 Crossref PubMed Scopus (1241) Google Scholar In nursing homes, two studies reported an incidence of 0.44 to 0.71 per patient month. 10 Gerety MB Cornell JE Plichta DT Eimer M Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc. 1993; 41: 1326-1332 Crossref PubMed Scopus (84) Google Scholar , 11 Cooper JW Drug-related problems in a geriatric long term care facility. J Am Geriatr Soc. 1986; 37: 323-326 Google Scholar Another study in 332 nursing home residents showed an incidence of 134 ADEs per 100 admissions. 12 Cooper JW Probable adverse drug reactions in rural geriatric nursing home population: A four year study. J Am Geriatr Soc. 1996; 44: 194-197 PubMed Google Scholar A recently published study conducted in 18 Massachusetts nursing homes 4 Gurwitz JH Field TS Avorn J et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000; 109: 87-94 Abstract Full Text Full Text PDF PubMed Scopus (526) Google Scholar found an incidence of 1.89 ADEs per 100 resident/months and potential ADEs in an additional 0.65 per 100 resident/months.