Medication Safety In Older Adults Research Articles

Generating creative solutions to address over-the-counter medication safety in older adults using invisible design

BackgroundParticipatory design (PD) is commonly used in human factors to develop and design interventions. Invisible design is a useful tool that can be applied in PD for generating intervention ideas with stakeholders, to solve complex problems without requiring end-users to be able to entirely articulate the “problem.” This study utilized invisible design to build a community-pharmacy intervention for older adults, to improve their over-the-counter medication safety. In the U.S., half of adults ages 65 and above (older adults) use over-the-counter medications (OTCs) unsafely. The purpose of this paper is to describe invisible design and highlight its value when designing system-level interventions. MethodsInvisible design is a scenario-based approach that allows participants to brainstorm solutions to an unseen problem. In this study, invisible design was used to elicit stakeholder feedback to inform a new pharmacy-based intervention designed to reduce OTC medication misuse. A series of video scenarios were developed to help stakeholders imagine solutions to the identified patient safety gaps in older adult medication selection and pharmacy interactions. ResultsStakeholders used the invisible design videos to imagine 52 solutions on how to address OTC medication safety in pharmacies. The solutions were grouped into three goals: (1) Facilitating Patient Autonomy, (2) Facilitating a Pharmacist-Patient Encounter, and (3) Facilitating Informed Pharmacist Recommendations. Many of these generated solutions were adopted as features of a pharmacy-based intervention, the Senior Section. ConclusionsInvisible design successfully led to the brainstorming of innovative solutions by key stakeholders and could be used to develop future interventions outside of the field of pharmacy.

Research status and hotspots of medication safety in older adults: A bibliometric analysis.

Medication safety is a significant concern in healthcare. Research on medication safety for older adults has taken a broad approach, resulting in a range of proposals. At this juncture, it is necessary to identify the main contributors and establish the current developmental status of the principal research topics. This study sets out to summarize the state-of-the-art in medication safety for older adults, identifying significant achievements, key topics, and emerging trends. The Web of Science Core Collection (WOSCC) database was searched for relevant documentation over the interval 1st January 2000 to 31st December 2021. Annual outputs and citations were identified from the WOS citation reports. CiteSpace and VOSviewer were adopted for bibliometric analysis and visualization that included the distribution of countries/regions, organizations, authors and journals, and an analysis of co-cited references and keywords. A total of 1,638 documents were retrieved for bibliometric analysis, yielding 34.29 citations per document. Publications have increased over the past two decades, reaching 177 outputs in 2019. Our database encompasses 71 countries/regions, 2,347 organizations, and 7,040 authors. The United States ranks first in terms of scientific activity with 604 publications (36.87%). We have identified the University of Sydney as the most prolific organization (53 publications). J. T. Hanlon, J. H. Gurwitz, D. O'Mahony, and G. Onder are the most influential researchers in terms of publications and citations. The Journal of the American Geriatrics Society ranks first with 89 (5.43%) papers. In terms of major research directions, three topics have been identified from co-cited reference and keyword analysis: (1) estimation of the prevalence and variables associated with polypharmacy and potentially inappropriate medication; (2) analysis of interventions involving pharmacists and the associated impact; (3) patient experience and perception associated with medication use or pharmaceutical care. Research on medication safety for older adults has progressed significantly over the past two decades. The United States, in particular, has made important contributions to this field. Polypharmacy and potentially inappropriate medication use, interventions involving pharmacists, patient experience and perception represent the current focus of research. Our findings suggest that these directions will continue as research hotspots in the future.

Understanding Hazards for Adverse Drug Events Among Older Adults After Hospital Discharge: Insights From Frontline Care Professionals.

Care transitions pose a high risk of adverse drug events (ADEs). We aimed to identify hazards to medication safety for older adults during care transitions using a systems approach. Hospital-based professionals from 4 hospitals were interviewed about ADE risks after hospital discharge among older adults. Concerns were extracted from the interview transcript, and for each concern, hazard for medication-related harms was coded and grouped by its sources according to a human factors and systems engineering model that views postdischarge ADEs as the outcome of professional and patient home work systems. Thirty-eight professionals participated (5 hospitalists, 24 nurses, 4 clinical pharmacists, 3 pharmacy technicians, and 2 social workers). Hazards were classified into 6 groups, ranked by frequencies of hazards coded: (1) medication tasks related at home, (2) patient and caregiver related, (3) hospital work system related, (4) home resource related, (5) hospital professional-patient collaborative work related, and (6) external environment related. Medications most frequently cited when describing concerns included anticoagulants, insulins, and diuretics. Top coded hazard types were complex dosing, patient and caregiver knowledge gaps in medication management, errors in discharge medications, unaffordable cost, inadequate understanding about changes in medications, and gaps in access to care or in sharing medication information. From the perspective of hospital-based frontline health care professionals, hazards for medication-related harms during care transitions were multifactorial and represented those introduced by the hospital work system as well as defects unrecognized and unaddressed in the home work system.

Understanding social workers’ hidden roles in medication safety for older adults: A qualitative study

ABSTRACT Older adults are vulnerable to risks associated with medications. This study explores the roles of Social Workers in facilitating medication safety for older adults. Eight social workers from federally qualified health centers participated in a case-based and interactive medication safety curriculum. They participated in an in-depth, semi-structured interview to explore their roles and strategies in assisting older adults and caregivers with medication management. Findings were transcribed and analyzed. Six themes characterizing social workers’ roles in medication management were identified: a) Referral: matching patients and medication-related resources within the health-care system and community; b) Communication: connecting providers, patients, caregivers, and support system; c) Access to medicine: addressing unique needs of each patient to foster their ability to obtain their medicines; d) Social Determinants of Health: investigating the social challenges of each patient and facilitating specific medication management approaches to meet identified needs; e) Engagement: engaging patients in co-developing a treatment plan; f) Caregiver Support: preparing caregivers to assist in medication management. Social workers are trained and well positioned to provide a multi-faceted approach to improve medication management for older adults. Their unique perspectives and skills are important in addressing the complex challenges of medication management.

Medication Safety in Older Adults: Learning From 2020 as We Launch into 2021.

In health care, the year 2020 is marked by the ongoing coronavirus (COVID-19) pandemic, with much research published to clarify infection risk, treatment approaches, and proposed interventions to reduce spread and combat complications. Although much work focused on COVID-19, medication safety remains a priority, and studies on adverse drug reactions, high-risk medications, and approaches to mitigate risk associated with chronic medication use, such as inappropriate dosing in hospital settings, were published. A continued commitment to patient-centered care, such as the approach put forth by the Age-Friendly Health Systems initiative and telehealth initiatives, ensures that even as health care practice strives to meet the challenge of an unprecedented global pandemic, safe medication use informed by patient needs continues to guide best practices through lessons learned. [Journal of Gerontological Nursing, 47(1), 7-11.].

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

Mobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use. This study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics. Twenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit. Overall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to "Good" to "Excellent" usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians. Consumer-facing technology can be a low-cost, scalable intervention to improve older adults' medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change.

Update on Medication Use Quality and Safety in Older Adults, 2017

Improving the quality of medication use and medication safety in older adults is an important public health priority and is of paramount importance for clinicians who care for them. We selected four important articles from 2017 that address these issues to annotate and critique, and we discuss the broader implications for optimizing medication use. A longer list of articles is given in an online appendix. The first study provides national data on the prevalence of central nervous system-active medication polypharmacy in older adults and how this has changed over a 9-year period (2004-2013). The second study characterizes prevalence of and factors associated with nonadherence to antiepileptic drugs in 36,912 older adults with epilepsy, with an emphasis on minorities. The third study describes the extent of antibiotic use in residents of 381 long-term care facilities (LTCF) in British Columbia, Canada, from 2007 to 2014. Finally, we discuss a meta-analysis of 42 studies that evaluated the prevalence of hospital admissions caused by adverse drug reactions in older adults. This article is intended to provide a narrative review of important publications on medication use quality and safety for clinicians and researchers committed to optimizing medication use in older adults. J Am Geriatr Soc 66:2254-2258, 2018.

Caregiver-Based Interventions to Optimize Medication Safety in Vulnerable Elderly Adults: A Systematic Evidence-Based Review.

To study the effect of caregiver-focused interventions to support medication safety in older adults with chronic disease. Systematic review. Studies published before January 31, 2017, searched using Ovid Medline, PubMed, EMBASE, Scopus, CINAHL, PsycINFO, and Google Scholar. Caregivers with or without a care recipient. Inclusion criteria: interventions focused on caregivers aiming to improve medication safety. Studies not focusing on older adults, not evaluating medication safety, failing to include caregivers, or without a comparison group were excluded. The initial search revealed 1,311 titles. Eight studies met inclusion criteria. The strategies used in randomized trials were a home-based medication review and adherence assessment by a clinical pharmacist (2 home visits 6-8 weeks apart, with pharmacist and physician meeting independently) that found no difference in nonelective hospital admissions (p=.8) but fewer medications (p=.03); a 19-minute educational DVD and an hour-long medication education and training that improved caregiver satisfaction (p<.04); a medication education and adherence intervention (2-3 home visits per care recipient and caregiver dyad over 8 weeks) that found no difference in knowledge, administration, or accessibility of medications (p=.29); and a collaborative case management program (16-month program of assessment, meeting, and monthly follow-up telephone calls) that reduced perceived caregiver burden (p=.03). Quasi-experimental trials included collaborative care transitional coaches, an outpatient collaborative care model, and education and training programs. Of these, educational interventions showed improvements in self-efficacy, confidence, and preparedness. The collaborative care intervention reduced rehospitalizations (p=.04) and improved quality-of-care outcomes. Although some interventions improved caregiver medication knowledge and self-efficacy, effects on clinical outcomes and healthcare use were insufficiently studied. Two studies implementing collaborative care models with medication management components showed potential for improvement in quality of clinical care and reductions in healthcare visits and warrant further study with respect to medication safety. J Am Geriatr Soc 66:2128-2135, 2018.

Meta-analysis of Interventions to Reduce Adverse Drug Reactions in Older Adults.

To examine the effect of interventions to optimize medication use on adverse drug reactions (ADRs) in older adults. Systematic review and meta-analysis. EMBASE, PubMed, OVID, Cochrane Library, Clinicaltrials.gov, and Google Scholar were searched through April 30, 2017. Randomized controlled trials. Older adults (mean age ≥65) taking medications. Two authors independently extracted relevant information and assessed studies for risk of bias. Discrepancies were resolved in consensus meetings. The outcomes were any and serious ADRs. Random-effects models were used to combine the results of multiple studies and create summary estimates. Thirteen randomized controlled trials involving 6,198 older adults were included. The studies employed a number of different interventions that were categorized as pharmacist-led interventions (8 studies), other health professional-led interventions (3 studies), a brief educational session (1 study), and a technology intervention (1 study). The intervention group was 21% less likely than the control group to experience any ADR (odds ratio (OR)=0.79, 95% confidence interval (CI)=0.62-0.99). In the six studies that examined serious ADRs, the intervention group was 36% less likely than the control group to experience a serious ADR (OR=0.64, 95% CI=0.42-0.98). Interventions designed to optimize medication use reduced the risk of any and serious ADRs in older adults. Implementation of these successful interventions in healthcare systems may improve medication safety in older adults.

Human Factors in Pharmacy

Medication errors in the ambulatory setting are common and contribute to significant morbidity and mortality. Given the Institute of Medicine’s recommendation of adopting a systems-based approach to improving medication safety, research has been conducted utilizing human factors and ergonomics conceptual frameworks, approaches, and methods to study pharmacies and pharmacists. This panel will focus on how human factors principles and models have been adapted for contexts where medications are managed. Individual projects address pediatric patients’ medication-related needs, over-the-counter medication safety for older adults, anticoagulation management, automated prescription tracking, and medication safety-related decision making by healthcare professionals. These studies span settings from community pharmacies to inpatient pharmacies to specialty clinics and patients’ homes. By presenting a sample of the growing body of human factors work in pharmacy, this panel will offer unique implications for human factors theory, methods, and application in this important domain.

Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED).

EQUiPPED is a multicomponent quality improvement initiative combining education, electronic clinical decision support, and individual provider feedback to influence prescribing and improve medication safety for older adults. The objective here was to evaluate the effectiveness and sustainability of EQUiPPED to reduce the use of potentially inappropriate medications (PIMs), as defined by the American Geriatrics Society 2012 Beers Criteria, prescribed to older Veterans at the time of emergency department (ED) discharge. This evaluation represents a pre- and post-intervention comparison of PIM prescriptions at 4 urban Veteran Affairs (VA) Medical Center EDs. Poisson regression was used to compare the number of PIMs prescribed to Veterans 65years or older discharged from the ED for at least 6months prior to the first EQUiPPED intervention at each site and for at least 12months following the final EQUiPPED intervention. The implementation timeline varied by site depending on local resources. All 4 sites showed a significant and sustained reduction in use of PIMs. The proportion of PIMs at site one decreased from 11.9% (SD 1.8) pre-EQUiPPED to 5.1% (SD 1.4) post-EQUiPPED (P<.0001); site 2 from 8.2% (SD 0.8) pre to 4.5% (SD 1.0) post (P<.0001); site 3 from 8.9% (SD 1.9) pre to 6.1% (SD 1.7) post (P=.0007); and site 4 from 7.4% (SD 1.7) pre to 5.7% (SD 0.8) post (P=.04). These results suggest a multicomponent program to influence provider prescribing behavior leads to safer prescribing for older adults discharged from the ED and is sustainable across multiple VA ED sites.

Recent Literature Update on Medication Risk in Older Adults, 2015-2016.

Medications can pose considerable risk in older adults. This article annotates four articles addressing this concern from 2016. The first provides national data on the use of specific prescription, over-the-counter and dietary supplements in older adults and their change over time. The second discusses the opportunity of deprescribing ineffective/unnecessary stool softeners (i.e., docusate) routinely given to older hospital patients. The third national study examines common adverse drug events in older emergency room patients. Finally, a study published demonstrating a potential association between melatonin and fractures is discussed. This manuscript is intended to provide a narrative review of key publications in medication safety for clinicians and researchers committed to improving medication safety in older adults.

Evaluation of an Educational Intervention on Knowledge and Awareness of Medication Safety in Older Adults with Low Health Literacy

ABSTRACTBackground: Older adults with low health literacy are at increased risk of nonadherence, accidental drug exposure, and adverse events. Purpose: This study evaluated older adults’ knowledge and awareness of medication safety and poison prevention resources using an interactive educational game compared to a less intensive intervention involving individual review of brochures. Methods: Both groups were given pre- and postintervention surveys to assess change in knowledge. Participants were followed up at 30 days to assess knowledge retention and behavior changes. Results: A total of 101 older adults participated in the study. In the game group, the median improvement in the index score pre- and postintervention was 3, moving from 9 (interquartile range [IQR] 6, 9) to 11 (IQR 9, 12). The brochure group median improvement was 1, moving from 7.5 (IQR 6, 8) to 8 (IQR 5, 10). Comparing postintervention to 30-day follow-up, over 50% of respondents retained the correct responses. Discussion: The interactive game significantly improved knowledge regarding use of child-resistant cap, interpreting a drug facts label, medication list documentation, and who to call for advice. Translation to Health Education Practice: This educational intervention has potential to increase awareness of poison prevention resources and medication safety strategies in older adults with low health literacy.

Improving over-the-counter medication safety for older adults: A study protocol for a demonstration and dissemination study.

Adverse drug events (ADEs) associated with over-the-counter (OTC) medications cause 178,000 hospitalizations each year. Older adults, aged 65 and older, are particularly vulnerable to ADEs. Of the 2.2 million older adults considered at risk for a major ADE, more than 50% are at risk due to concurrent use of an OTC and prescription medication. To refine the intervention and implementation strategy through diagnostic and formative evaluation; to evaluate the effectiveness of the intervention for preventing misuse of high-risk OTC medications by older adults; and to evaluate the implementation of the intervention in community pharmacies. A system redesign intervention to decrease high-risk OTC medication misuse will be tested to reduce misuse by improving communication between older adults and community pharmacists via the following features: a redesign of the physical environment to sensitize older adults to high-risk OTC medications, and the implementation of a clinical decision tool to support the pharmacist when critically evaluating the older adult's health status. The study will be conducted in three phases: a participatory design phase, a beta phase, and a test phase. The test phase will be conducted in three mass-merchandise stores. A total of 144 older adults will be recruited. A pre (control)/post (intervention) test will determine the effectiveness of the intervention. The primary outcome will be a comparison of proportion of older adults who misuse OTC medication from baseline to post-intervention. The process of implementation in the community pharmacy setting will be evaluated using the taxonomy proposed by Proctor etal. The participatory design phase has been approved by the institution's IRB (2016-0743). It is anticipated that this project, which focuses on achieving systems-based improvement in an underemphasized area of the medication use process, will reduce ADEs associated with inappropriate OTC medication use in older adults.

Updated Beers Criteria: A more comprehensive guide to medication safety in older adults

P from all practice settings are likely familiar with the American Geriatric Society’s (AGS) Beers Criteria of Potentially Inappropriate Drugs, last published in 20121 and recently revised and updated in 2015.2 The AGS Beers Criteria—Beers Criteria for short—have proven useful in identifying drugs to potentially avoid in older adults, to reduce adverse drug events and drug-related problems, and to improve medication selection and overall medication safety in older adults. The Beers Criteria are designed for use in any clinical setting and can also be used as an educational quality measure and research tool. The latest version of the Beers Criteria uses a more comprehensive, systematic review and grading of evidence.

Tackling Communication Barriers Between Long-Term Care Facility and Emergency Department Transfers to Improve Medication Safety in Older Adults.

In 2013, the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine created geriatric emergency department guidelines, making recommendations for staffing/administration, follow up and transitions of care, education, quality improvement, equipment/supplies, and other policies, procedures, and protocols to be implemented. Awareness of these guidelines, as well as communication barriers, can help improve the delivery of care for older adults during transitions in care, particularly regarding medication safety.

2012 American Geriatrics Society Beers Criteria: New Year, New Criteria, New Perspective

Mark Beers, MD, recognized more than 2 decades ago that the prevention of adverse drug events in older adults is crucial to the public health of this vulnerable population. The Beers Criteria remain simultaneously one of the most used and most controversial sets of medication criteria in the world. Although not without limitations, the Beers Criteria have done more than any other tool in the past decade to improve the awareness of and clinical outcomes for older adults with polypharmacy and for the most vulnerable older adults at risk of adverse drug events. They have accomplished this because of their explicit nature, simple application for nonpharmacy experts, and wide dissemination. The continued development of explicit lists of medications to avoid in older adults, such as the Beers Criteria, is a critical component, albeit not the only one, in the public health imperative to decrease drug-related problems and improve the health of older adults. Nevertheless, continuing challenges include evaluating and communicating a drug’s risks and benefits in older adults to individual clinicians across all settings of care and developing an explicit list of these medications as part of a concise document that meets the needs of patients, clinicians, educators, researchers, policy-makers, and regulators. This article provides a perspective from the co-chairs of the 2012 American Geriatrics Society (AGS) Beers Criteria by addressing these issues, exploring the major differences and intended use of the criteria in this AGS-sponsored update, and proposing an agenda for future work. The authors believe the 2012 criteria are vastly improved from previous iterations because they include important updates to the established method for developing the explicit list of medications to avoid in older adults and consider the challenges of guiding individual clinicians in avoiding certain drugs in older adults or using them with caution. Most importantly, the quality of the criteria has been improved by the application of an evidence-based approach and the support of AGS. The decision to follow the Institute of Medicine standards for evidence and transparency was an important benchmark—one that was clearly a transition for criteria that have been traditionally developed using a Delphi consensus process. Because of the nature of clinical drug trials in older adults, evidence was at times difficult to find and to apply cleanly. The literature search was complex because of the large number and diversity of search terms required, the extended time period searched, and the lack of clinical trial data in older adults often resulting in reliance on observational data. With AGS support, the development of databases to support more-frequent updates of the criteria and continual grading of the evidence as it emerges will continue to enhance this process. Past criticisms of the Beers Criteria correctly pointed out that many of the drugs were off the market or not in widespread use, lessening their relevance to clinicians and their association with health outcomes. The support of AGS has made this list more dynamic and relevant to the real-world practice of medicine. Still, caveats in their recommendation or rationale complicate some of the resulting criteria. These caveats offer additional guidance to clinicians about when to avoid a drug but at times cannot be used as a performance measure if extracted from a large database or by surveyors without sufficient clinical insight to discern these nuances. The Beers Criteria are situated within a larger perspective of strategies to improve medication safety in older adults. Previous studies have found that a small number of medications are responsible for most adverse drug events in older adults. In a recent study, four medications or medication classes (warfarin, insulin, oral antiplatelet agents, and oral hypoglycemic agents) were associated with most

Adverse Events in Elderly Mostly From Common Drugs

Nearly 100,000 Americans aged 65 years and older are hospitalized each year after adverse drug events, and most of these emergencies result from a few commonly used medications, according to a study from the Centers for Disease Control and Prevention. Of an estimated 99,628 hospitalizations—about half coming among people aged 80 years and older—66% were the result of unintentional overdoses, Dr. Daniel S. Budnitz, director of the CDC's Medication Safety Program, and his colleagues reported in the New England Journal of Medicine. The medications most often implicated were warfarin, insulins, oral anti-platelet agents, and oral hypoglycemic agents, which either alone or in combination accounted for 33%, 14%, 13%, and 11% of the hospitalizations, respectively, the investigators reported (N. Engl. J. Med. 2011;365:2002-12). Emergency department visits resulting in hospitalization were more likely than those not resulting in hospitalization to involve unintentional overdoses (66% vs. 46%) and to involve at least five medications (55% vs. 40%). The researchers noted that medications typically deemed high risk or inappropriate for elderly patients resulted in relatively few emergency hospitalizations, accounting for only about 1% and 7% of the 65-and-over emergency admissions, respectively. The findings have important implications for reducing harm and health care costs among older adults, said Dr. Budnitz and his colleagues. Such detailed and drug-specific data can help focus current patient-safety efforts, such as the Partnership for Patients, they said. That $1 billion federal initiative has the goal of decreasing preventable hospitalizations 20% by the end of 2013. The investigators used adverse-event data for 2007 through 2009 from the National Electronic Injury Surveillance System—Cooperative Adverse Drug Event Surveillance Project. They based their national estimates on an analysis of 5,077 emergency hospitalizations in older adults at 58 nonpediatric hospitals that participate in the surveillance system. The numbers probably represent underestimates of emergency hospitalizations, the investigators said. They explained that some patient groups—such as those admitted for diagnostic evaluation or transferred from other hospitals—were not represented in the analysis. “Our findings suggest that efforts to improve medication safety for older adults should focus on areas in which improvements are most likely to have sizable, clinically significant, and measurable effects, such as improving the management of antithrombotic and antidiabetic drugs,” the investigators concluded. In a press statement, Dr. Budnitz acknowledged that blood thinners and diabetes medications are critical medicines for many older adults. “Doctors and patients should continue to use them but remember to work together to safely manage them,” he said. Neither Dr. Budnitz nor any of the other investigators disclosed any conflict of interest.

Medication Literacy Is a 2-Way Street

Medication Literacy Is a 2-Way Street

Medication Safety in Older Adults: Home‐Based Practice Patterns

To identify the current state of medication-taking practices of community-dwelling older adults on high-risk medications. Telephone survey of older adults filling prescriptions for warfarin, digoxin, or phenytoin from May 2, 2002, through June 30, 2003. The Pennsylvania Pharmacy Assistance Contract for the Elderly (PACE) Program, a state-run program providing prescription drug coverage for poor older adults. PACE members. Patients self-reported sources of information on current medications as well as home-based practices for organizing medication regimens. Four thousand nine hundred fifty-five PACE members were interviewed. Thirty-two percent of the sample reported that they had not received any specific instructions about their medications, 35% reported that they received instructions from their primary care provider, and 46% indicated they received them from a pharmacist. Fifty-four percent of participants indicated that they used a pillbox for organizing their medications. Older adults prescribed warfarin were more likely to report receiving instructions than those prescribed digoxin or phenytoin. A substantial proportion of older adults on high-risk medications do not recall receiving instructions for the use of their medications and do not take advantage of existing systems for organizing medication regimens. Improved patient education and delivery of medication organization systems are immediate opportunities to potentially reduce the risk of medication errors in older people.