Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

Yan Xiao; Aaliyah Smith; Ephrem Abebe; Susan M Hannum; Andrea M. Wessell; Ayse P. Gurses

Study

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;18(8):e1174-e1180.

View more articles from the same authors.

Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.

PubMed citation

Available at

Related Resources From the Same Author(s)

Engineering care transitions: clinician perceptions of barriers to safe medication management during transitions of patient care.

May 19, 2021

Engineering a foundation for partnership to improve medication safety during care transitions.

February 6, 2019

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals.

May 26, 2021

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

July 27, 2022

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

Disparities in adverse event reporting for hospitalized children.

August 3, 2022

Ambulatory medication safety in primary care: a systematic review.

July 6, 2022

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

A systematic review of the literature on multidisciplinary rounds to design information technology.

March 15, 2006

Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients?

January 8, 2020

Challenges and strategies for patient safety in primary care: a qualitative study.

September 28, 2022

Why is patient safety a challenge? Insights from the Professionalism Opinions of Medical Students' research.

November 2, 2022

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

Predictors of serious opioid-related adverse drug events in hospitalized patients.

July 8, 2020

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology.

May 19, 2021

August 19, 2020

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

Characteristics of critical incident reporting systems in primary care: an international survey.

January 19, 2022

The impact of adverse events on clinicians: what's in a name?

November 22, 2017

A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients.

March 2, 2022

Medication order errors at hospital admission among children with medical complexity

July 8, 2020

Medication errors at hospital admission and discharge: risk factors and impact of medication reconciliation process to improve healthcare.

October 20, 2021

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis.

September 2, 2020

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support.

May 18, 2022

Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery.

August 10, 2022

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

Data collection for adverse events reporting by US dental schools.

September 30, 2020

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

November 17, 2021

Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients.

May 18, 2022

A machine learning approach to reclassifying miscellaneous patient safety event reports.

July 29, 2020

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Usability and accessibility of publicly available patient safety databases.

June 1, 2022

Addressing patient safety hazards using critical incident reporting in hospitals: a systematic review.

January 18, 2023

Understanding patient and clinician reported nonroutine events in ambulatory surgery.

March 22, 2023

Adverse event reporting priorities: an integrative review.

June 29, 2022

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Medication reconciliation during hospitalization and in hospital-home interface: an observational retrospective study.

April 7, 2021

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States.

June 22, 2022

The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department.

July 27, 2022

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening.

June 15, 2022

The patients' perspective: hematological cancer patients' experiences of adverse events as part of care.

August 18, 2021

Teamwork before and during COVID-19: the good, the same, and the ugly….

August 24, 2022

National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies.

March 3, 2021

Identifying boundary spanning reporter roles in patient safety events.

August 24, 2022

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

May 11, 2022

How accurately do older adult emergency department patients recall their medications?

August 12, 2020

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

December 16, 2020

What contributes to diagnostic error or delay? A qualitative exploration across diverse acute care settings in the United States.

May 26, 2021

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

Why an open disclosure procedure is and is not followed after an avoidable adverse event.

September 8, 2021

Burnout, engagement, and dental errors among U.S. dentists.

December 22, 2021

Long-term impacts faced by patients and families after harmful healthcare events.

December 15, 2021

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study.

September 23, 2020

Patient factors and hospital outcomes associated with atypical presentation in hospitalized older adults with COVID-19 during the first surge of the pandemic.

August 18, 2021

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.

June 16, 2021

Identification of adverse events in ground transport emergency medical services.

September 14, 2011

Encouraging patients to speak up about problems in cancer care.

January 12, 2022

Reducing near miss medication events using an evidence-based approach.

July 27, 2022

Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults.

September 1, 2021

Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.

April 27, 2022

Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.

October 26, 2022

We are not there yet: a qualitative system probing study of a hospital rapid response system.

April 20, 2022

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

Patient safety issues from information overload in electronic medical records.

September 14, 2022

Exploring care left undone in pediatric nursing.

September 28, 2022

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

June 15, 2022

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

Patient perceptions of hospital experiences: implications for innovations in patient safety.

March 16, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

Costs of intravenous adverse drug events in academic and nonacademic intensive care units.

January 16, 2008

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

Trends in adverse event rates in hospitalized patients, 2010-2019.

July 27, 2022

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.

December 14, 2022

Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.

September 1, 2021

The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program.

April 13, 2022

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.

August 17, 2022

Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses.

June 9, 2021

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

January 18, 2023

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

August 10, 2022

Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.

August 10, 2022

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.

July 28, 2021

Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.

September 21, 2022

Association of current opioid use with serious adverse events among older adult survivors of breast cancer.

October 14, 2020

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

February 2, 2022

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Frequency and nature of communication and handoff failures in medical malpractice claims.

April 6, 2022

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.

February 22, 2023

Related Resources

Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS.

April 17, 2024

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

December 6, 2023

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

September 13, 2023

Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis.

August 2, 2023

Family conferences to facilitate deprescribing in older outpatients with frailty and with polypharmacy: the COFRAIL cluster randomized trial.

May 10, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Journal Article

Study

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

March 29, 2023

Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool.

January 25, 2023

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

January 25, 2023

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

January 18, 2023

Medication errors: the year in review: January through December 2021.

January 11, 2023

Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.

December 21, 2022

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial.

November 30, 2022

Safety considerations for challenges when using smart infusion pumps.

November 2, 2022

WebM&M Cases

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

September 28, 2022

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

August 10, 2022

Individualized medication review in older people with multimorbidity: a comparative analysis between patients living at home and in a nursing home.

May 25, 2022

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse.

April 20, 2022

Medication discrepancy rates and sources upon nursing home intake: a prospective study.

April 6, 2022

Sources of medication omissions among hospitalized older adults with polypharmacy.

March 9, 2022

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

February 23, 2022

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

February 2, 2022

Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients.

December 22, 2021

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

July 21, 2021

Geriatric medication reconciliation in the home setting.

July 21, 2021

Administration of concentrated potassium chloride for injection during a code: still deadly!

June 30, 2021

See More About The Topic

Hospitals

Home Care

Quality and Safety Professionals

Geriatrics

Hospital Pharmacy

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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