… Journal of managed care & specialty pharmacy … J Manag Care Spec Pharm … This retrospective study reviewed … period, the number of serious ADEs reported doubled and a small number of medications accounted for a significant number of serious and fatal ADEs. …

Patients in nursing homes are generally elderly, chronically ill, and take multiple medications, which places them at higher risk for medication errors. The state of North Carolina maintains a mandatory medication error reporting system for all nursing homes. This study analyzed data from this system to characterize errors due to anticoagulant drugs (which are considered high-risk medications). Errors were found to be common and harmful, often due to inadequate monitoring to ensure appropriate drug dosing. The authors recommend several potential solutions, but any interventions will likely also have to address the fact that safety culture in nursing homes is generally poor. An AHRQ WebM&M commentary discusses a preventable error due to inadequate monitoring of the anticoagulant warfarin at a nursing home, and an AHRQ WebM&M perspective explores the difficult problem of ensuring medication safety in nursing facilities.

All North Carolina nursing homes are required to report medication error data. This study reports on a pilot effort to feed back data on error rates to individual nursing homes.

This study applied a novel analytic tool to identify rates and patterns of medication error reporting. For example, warfarin was disproportionately co-reported with communication errors just as oxycodone and morphine were with name confusion.

This study found that 37% of medication errors were repeated one or more times in nursing home settings, with wrong dosage and wrong administration as the most frequent causes. While the absolute harm rates were small, repeat errors were twice as likely to be harmful to patients compared to non-repeated ones.

North Carolina law requires all nursing homes to report medication errors, as discussed in a prior article. Analysis of medication error reports submitted to this Web-based error reporting system revealed that most of the serious errors occurred during evening shifts and involved drugs given to the wrong patient.

… health care … Qual Saf Health Care … Medication errors are a common, costly , and dangerous problem for residents of …

… The American journal of geriatric pharmacotherapy … Am J Geriatr Pharmacother … Scrutiny over the quality of care … emerging safety priority. Medication safety and fostering a safety culture  are previously identified needs, but greater attention to ensure safer care transitions is a targeted goal. This study analyzed medication errors …