Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

Becky Briesacher; Rhona Limcangco; Linda Simoni-Wastila; Jalpa Doshi; Jerry H Gurwitz

Study

Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

June 22, 2005

Briesacher B, Limcangco R, Simoni-Wastila L, et al. J Am Geriatr Soc. 2005;53(6):991-6.

View more articles from the same authors.

This study explored the effect of a Centers for Medicare and Medicaid Services policy on inappropriate medication use in nursing homes. The authors conclude that the effect of nationally mandated drug reviews is unclear and suggest that more effective safeguards are needed.

PubMed citation

Available at

Related Resources From the Same Author(s)

Adverse drug events resulting from patient errors in older adults.

March 7, 2007

An interview with Jerry Gurwitz.

November 29, 2006

Drug shortages and clinicians: no time for complacency.

October 3, 2012

The effect of universal glove and gown use on adverse events in intensive care unit patients.

September 30, 2015

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.

July 22, 2009

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

November 28, 2012

Communicating with patients about medical errors: a review of the literature.

March 6, 2005

Meaningful use of health information technology and declines in in-hospital adverse drug events.

March 8, 2017

The effect of contact precautions on frequency of hospital adverse events.

December 9, 2015

Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

January 18, 2006

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

October 26, 2005

Beyond the prescription: medication monitoring and adverse drug events in older adults.

August 31, 2011

Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety.

September 9, 2009

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

November 7, 2007

The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review.

April 16, 2008

The costs associated with adverse drug events among older adults in the ambulatory setting.

December 7, 2005

Disclosure of medical errors: what factors influence how patients respond?

June 21, 2006

Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications.

March 18, 2009

Prescribers' responses to alerts during medication ordering in the long term care setting.

August 30, 2006

Health plan members' views about disclosure of medical errors.

March 6, 2005

The safety of warfarin therapy in the nursing home setting.

June 13, 2007

Adverse events in long-term care residents transitioning from hospital back to nursing home.

August 7, 2019

Dementia and risk of adverse warfarin-related events in the nursing home setting.

November 21, 2012

Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Medication errors among adults and children with cancer in the outpatient setting.

January 14, 2009

The incidence of adverse drug events in two large academic long-term care facilities.

April 15, 2005

Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.

August 30, 2017

The association of nursing home characteristics and quality with adverse events after a hospitalization.

April 28, 2021

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

February 23, 2011

An exploration of safety climate in nursing homes.

August 8, 2012

Medication errors in the homes of children with chronic conditions.

January 30, 2005

Strategies for detecting adverse drug events among older persons in the ambulatory setting.

March 6, 2005

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

February 11, 2009

FDA drug prescribing warnings: is the black box half empty or half full?

December 7, 2005

Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.

November 13, 2013

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting.

August 11, 2010

Potential medication dosing errors in outpatient pediatrics.

January 11, 2006

Medication discrepancies upon hospital to skilled nursing facility transitions.

April 29, 2009

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites.

August 19, 2009

Rudeness at work.

July 21, 2010

Measuring safety culture in healthcare: a case for accurate diagnosis.

June 27, 2007

Senior charge nurses' leadership behaviours in relation to hospital ward safety: a mixed method study.

November 27, 2013

Review article: the influence of psychology and human factors on education in anesthesiology.

January 30, 2005

Patient safety in surgery: non-technical aspects of safe surgical performance.

April 7, 2010

Hospital safety climate surveys: measurement issues.

October 20, 2010

Evolution of a rapid response system from voluntary to mandatory activation.

June 9, 2010

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.

November 18, 2015

Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up.

October 29, 2014

Influencing leadership perceptions of patient safety through just culture training.

May 5, 2010

Team communication during patient handover from the operating room: more than facts and figures.

April 24, 2013

Communication skills and error in the intensive care unit.

November 28, 2007

Dangerous deception--hiding the evidence of adverse drug events.

November 29, 2006

Towards a model of surgeons' leadership in the operating room.

March 9, 2011

Impact of a pharmacotherapy alerting system on medication errors.

January 23, 2013

Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists.

December 11, 2013

The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis.

February 29, 2012

Team situation awareness and the anticipation of patient progress during ICU rounds.

August 10, 2011

Developing a team performance framework for the intensive care unit.

May 6, 2009

Doctors' handovers in hospitals: a literature review.

March 2, 2011

Year 1 medical undergraduates' knowledge of and attitudes to medical error.

December 16, 2009

No harm found when nurse anesthetists work without supervision by physicians.

August 11, 2010

High-risk, high-alert medication management practices in a regional state psychiatric facility.

May 9, 2007

Nurses' communication of safety events to nursing home residents and families.

November 15, 2017

Dispensing error rate in a highly automated mail-service pharmacy practice.

November 23, 2005

Your company's secret change agents.

May 25, 2005

Racism in pain medicine: we can and should do more.

July 14, 2021

Are you listening...Are you really listening?

September 17, 2008

Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system.

March 5, 2008

Medication-attributed adverse effects in placebo groups: implications for assessment of adverse effects.

January 31, 2006

Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.

September 14, 2011

Patient safety: helping medical students understand error in healthcare.

August 22, 2007

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.

February 17, 2016

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

June 7, 2017

Temporal clustering of critical illness events on medical wards.

July 26, 2023

Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000–2010.

January 25, 2017

Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs.

August 28, 2013

Is electronic health record safety a paradox?

February 23, 2022

Managing the care of patients discharged from home health: a quiet threat to patient safety?

April 4, 2007

Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies.

August 30, 2023

Collaborating—or "selling" patients? A conceptual framework for emergency department-to-inpatient handoff negotiations.

March 18, 2015

Nurse–physician teamwork in the emergency department: impact on perceptions of job environment, autonomy, and control over practice.

May 8, 2013

An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety.

January 11, 2012

Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.

May 11, 2005

Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.

March 6, 2005

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

April 7, 2010

Defining attributes of patient safety through a concept analysis.

July 15, 2015

Just culture: it's more than policy.

August 7, 2019

Using simulation training to improve perioperative patient safety.

April 17, 2013

Preprinted order sets as a safety intervention in pediatric sedation.

February 25, 2009

The working hours of hospital staff nurses and patient safety.

January 9, 2005

Guided prescription of psychotropic medications for geriatric inpatients.

May 18, 2005

Understanding patient safety and quality outcome data.

March 20, 2019

Teaching students to administer medications safely.

April 19, 2017

Long-term reduction in adverse drug events: an evidence-based improvement model.

July 18, 2012

Nurses' clinical reasoning: processes and practices of medication safety.

September 28, 2011

What is learning? A review of the safety literature to define learning from incidents, accidents and disasters.

February 19, 2014

Sources of nurse-sensitive inpatient safety improvement.

December 21, 2022

Hospital quality-review spending and patient safety: a longitudinal analysis using instrumental variables.

July 7, 2021

Related Resources

Do not PIMP my nursing home ride! The impact of Potentially Inappropriate Medications Prescribing on residents' emergency care use.

September 20, 2023

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

April 19, 2023

Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic.

April 5, 2023

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

March 1, 2023

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

February 1, 2023

Electronic health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical Health Act.

December 21, 2022

Patient safety culture in assisted living: staff perceptions and association with state regulations.

November 30, 2022

National Healthcare Quality and Disparities Reports.

November 7, 2022

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

October 12, 2022

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

Impact of medication reviews on potentially inappropriate medications and associated costs among older women in aged care.

September 21, 2022

Concordance of hospital ranks and category ratings using the current technical specification of US Hospital Star Ratings and reasonable alternative specifications.

August 31, 2022

Risk reduction strategy to decrease incidence of retained surgical items.

August 31, 2022

Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.

August 24, 2022

Health care quality and safety in a correctional system: creating goals and performance measures for improvement.

August 17, 2022

Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.

August 10, 2022

May 4, 2022

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.

March 30, 2022

COVID-19 Focused Inspection Initiative in Healthcare.

March 23, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

February 24, 2022

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

February 2, 2022

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

January 12, 2022

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings.

October 6, 2021

Phony diagnoses hide high rates of drugging at nursing homes.

September 22, 2021

Organizational readiness to change as a leverage point for improving safety: a national nursing home survey.

September 8, 2021

Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids.

August 25, 2021

Long-term care nurses' experiences with patient safety incident management: a qualitative study.

August 4, 2021

Community discharge among post-acute nursing home residents: an association with patient safety culture?

June 30, 2021

See More About The Topic

Long-Term Care

Facility and Group Administrators

Quality and Safety Professionals

Policy Makers

Side Effects/Adverse Drug Reactions

Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site