… to assess and improve this important quality process.  … Fischer SH,  Shih RA, McMullen TL, et al. Standardized …

Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.

Electronic health record alerts contribute to alert fatigue and increase provider workload. Some alerts are more time-sensitive than others and a delayed response can adversely impact patient safety. This study found that time-sensitive alerts were less likely to be opened by primary care providers within 24 hours if the provider's InBasket had a high number of notifications at the time of alert delivery or if the alert was sent on the weekend.

Although medication reconciliation is widely advocated to improve medication safety, barriers to implementation persist. This commentary describes strategies to improve the process to ensure patients and care teams have accurate medication lists. Recommendations include involving the patient in reconciliation and clarifying which provider is responsible for the task.

Determining the severity of harm or potential harm is a challenge in patient safety. Investigators asked physicians, nurses, and pharmacists to rate the severity of harm for specific adverse events including falls, health care–associated infections, pressure ulcers, and blood product errors. The authors recommend using two raters to determine harm in order to achieve reliable estimates.

E-prescribing is a key strategy to improve medication safety by addressing illegible prescriptions, order omissions, and dosage confusion. However, there have been unintended consequences such as the inability to discontinue medications ordered electronically. This commentary reviews problems associated with this unintended consequence and suggests that enabling electronic cancellation of prescriptions can help address the issue. A WebM&M commentary discussed a case involving an electronic prescribing error.

Clinical pharmacists retrospectively reviewed ambulatory records to identify adverse drug events following hospital discharge among patients aged 65 years and older. As in prior studies, frequent adverse drug events were found involving a wide range of medications, not limited to potentially inappropriate medications as defined by Beers criteria.

Dementia appeared to be an independent risk factor for medication errors among a cohort of geriatric nursing home patients who were prescribed the anticoagulant warfarin. Increased nursing staff time seemed to mitigate this risk.

This study reports on the initial findings of a novel survey intended to evaluate safety culture in nursing homes, the Survey on Resident Safety in Nursing Homes.

Warfarin therapy is commonly associated with adverse events despite specific indicators designed to capture them and guide prevention efforts. This study adopted the SBAR communication tool as part of a protocol to improve the quality of warfarin management in the nursing home setting. Using a facilitated telephone communication between nurses and physicians in 26 nursing homes, the patients randomized to the SBAR approach had statistically significant improvements in their therapeutic levels and a non-statistically significant reduction in adverse events. A past AHRQ WebM&M commentary discusses a case of inadequate warfarin monitoring that resulted in an adverse event for a nursing home patient.

Failure to follow up on test results has been linked to missed and delayed diagnoses in the ambulatory setting. Although electronic health records (EHR) hold great promise for addressing this issue, this systematic review found only modest published evidence linking EHR use to improved laboratory test monitoring. This finding corroborates other studies documenting persistent failure to comprehensively follow up abnormal lab tests and radiologic studies despite use of an EHR. The authors conclude that further research will be required to develop optimal test management systems within electronic medical records.

This study reports on the development of standards for laboratory monitoring of high-risk medications (such as anticoagulants) in ambulatory care. Pilot testing revealed that the developed guidelines were not being consistently followed, with infrequently prescribed medications most likely to be monitored inappropriately.

Prior studies have documented suboptimal safety culture in long-term care facilities. This AHRQ-funded study used surveys and interviews to examine one specific aspect of safety culture—communication between nurses and physicians. Nurses noted several problems with communication, including lack of receptiveness by physicians and difficulty reaching physicians. Many nurses noted instances of unprofessional or disruptive behavior by physicians. Nurses acknowledged the need to use structured communication protocols as a means of improving communication. Patient harm can result from a physician's failure to acknowledge a nurse's concerns about patients, as illustrated in this AHRQ WebM&M commentary.

This study discovered that clinical decision support built within a CPOE system can improve physician prescribing behavior in long-term care settings.

Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to medication errors, as they are often elderly, have multiple chronic illnesses, and take multiple medications. In this study, medication discrepancies (among the hospital discharge summary, SNF referral form, and SNF admission orders) were the rule rather than the exception. Most concerning, many discrepancies involved high-risk medications such as opioid analgesics, anticoagulants, and hypoglycemic agents, which have been linked to serious medication errors in elderly patients. While The Joint Commission has mandated medication reconciliation for long-term care facilities as part of the 2009 National Patient Safety Goals, the authors note that many SNFs do not maintain Joint Commission accreditation, implying that state or national regulations may be needed to improve medication safety across the hospital–SNF transition.

Medication administration in long-term care facilities is a lengthy process, and the large number of interruptions nurses experience during the process may lead to errors.

Adverse drug events (ADEs) are common in the long-term care setting, in part because many residents are prescribed high-risk medications such as sedatives and anticoagulants. This cluster-randomized trial evaluated the effectiveness of a computerized provider order entry (CPOE) system at preventing ADEs in two long-term care facilities. The system was largely ineffective at preventing errors, with no significant difference in ADE incidence between intervention and control units. Limitations of the CPOE system likely contributed to the null result, as the system created many unnecessary alerts and had only limited decision support capabilities. An AHRQ WebM&M commentary discusses a case of a medication error associated with warfarin use at a skilled nursing facility.

This review examined the impact of computerized physician order entry with clinical decision support on the incidence of adverse drug events (ADEs) and found that currently available research was limited to hospital settings and half of the studies showed a statistically significant decrease in ADEs.

The anticoagulant warfarin is considered a high-risk medication, as it is a common cause of adverse drug events (ADEs) in the outpatient setting. In this retrospective study, the investigators reviewed nursing home records to determine the incidence and preventability of warfarin-related ADEs. Patients were at substantial risk of serious ADEs such as bleeding complications, which occurred at a rate of 2.49 events per 100 resident-months. Approximately one-third of the errors were considered preventable, primarily due to failure to adequately monitor warfarin dosing or account for medication interactions. A prior AHRQ WebM&M commentary discusses an example of inadequate warfarin monitoring resulting in adverse consequences for a nursing home patient.

In this AHRQ–funded study, the investigators analyzed prescriber response to alerts generated by computerized physician order entry (CPOE) with a clinical decision support system.