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Irons MW, Auta A, Portlock JC, et al. Home Health Care Serv Q. 2022;41:91-123.
Care home residents experience high rates of medication errors. Thirty-two articles about medication errors in UK care homes were included in this review. Articles covered causes, rates, recommendations, and/or evaluation of interventions on error rates. The authors recommend development of more robust strategies for evaluating medication errors in care homes.
Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11:e054364.
Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.
Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;17:e988-e994.
It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.
Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51:520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.

The Society for Post-Acute and Long-Term Care Medicine.

Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning network to share aggregated data, lessons learned, and educational opportunities to reduce medication adverse events through safe deprescribing. 
Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty, inpatient, and community-based care.
Elbeddini A, Almasalkhi S, Prabaharan T, et al. J Pharm Policy Pract. 2021;14:10.
Medication reconciliation can improve patient safety, but prior research has documented challenges with implementation. Researchers conducted a gap analysis to inform the development of standardized medication reconciliation framework for use across multiple healthcare settings to reduce harm, including during the COVID-19 pandemic. Five key components were identified: (1) pharmacy-led medication reconciliation team, (2) patient education and involvement, (3) complete and accurate medication history, (4) admission and discharge reconciliation, and (5) interprofessional communication.
Dellinger JK, Pitzer S, Schaffler-Schaden D, et al. BMC Geriatr. 2020;20:506.
Polypharmacy in older adults is common and may increase risk of medication-related adverse events. This study found that an intervention combining educational training, tailored health information technology, and a therapy check process improved medication appropriateness in nursing home residents.  
Kane‐Gill SL, Wong A, Culley CM, et al. J Am Geriatr Soc. 2020;69:530-538.
Medication reconciliation and medication regimen reviews can reduce adverse drug events (ADEs) in older adults. This study assessed the impact of a pharmacist-led, patient-centered telemedicine program to manage high-risk medications during transitional and nursing home care. The program included telemedicine-based medication reconciliation at admission and medication regimen reviews throughout the nursing home stay, coupled with clinical decision support. Residents in the program experienced fewer adverse drug events compared to a usual care group. This innovative model has the potential to further reduce medication errors in nursing home residents.
Choudhury A, Asan O. JMIR Med Inform. 2020;8:e18599.
This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.  
Balsom C, Pittman N, King R, et al. Int J Clin Pharm. 2020:Epub Jun 3.
Polypharmacy is one risk factor for medication errors in older adults. This study describes the implementation of a pharmacist-administered deprescribing program in a long-term care facility in Canada. Over a one-year period, residents were randomized to receive either a deprescribing-focused medication review by a pharmacist or usual care. The intervention resulted in fewer medications taken by residents the intervention group after 6 months. Most deprescribing recommendations reflected a lack of ongoing indication or a dosage that was too high.
Elliott RA, Camacho E, Jankovic D, et al. BMJ Qual Saf. 2021;30:96-105.
This study combined previously published error prevalence estimates in the United Kingdom to estimate the annual number and burden of medication errors to the National Health Service (NHS). The authors estimate that 237 million medication errors occur annually in the UK. The majority of errors occur during medication administration and prescribing and occur most frequently in long-term care and primary care settings. While the majority of errors have little or no potential for harm, 66 million errors were deemed potentially clinically significant; prescribing in primary care settings accounts for one-third of these potentially significant errors. These medication errors result in hospital admissions or longer length of stay, as well as death. 
Amin PB, Bradford CD, Rizos AL, et al. J Pharm Pract. 2020;33:306-313.
This pilot study evaluated the impact of transitional care pharmacist medication-related interventions in skilled nursing settings on 30-day hospital readmissions. The intervention group received transitional services involving a pharmacist (such as medication reconciliation, coordination with the skill nursing case manager and physician, and patient/caregiver education) and the control group received transitional services without pharmacist involvement. Over the follow-up period, median time to readmission was significantly longer in the intervention group but 30-day readmission rates were non-statistically significantly lower in the intervention compared to control group.
Leguelinel-Blache G, Castelli C, Rolain J, et al. Expert Rev Pharmacoecon Outcomes Res. 2020;20:481-490.
The value of medication reviews in reducing adverse drug events (ADEs) is now generally accepted although robust evidence of cost or clinical effectiveness of such reviews is lacking. For this pilot study of patients in a French nursing home, ADE risk scores were calculated before and six months after a pharmacist-led multidisciplinary review of each patient’s medications. Significant drops in ADE risk scores, as well as reductions in the number of patients taking at least one potentially inappropriate medication and substantial cost savings for the nursing home, are reported in this preliminary assessment.
The Associated Press. Flu shot mix-up at Oklahoma facility leaves 10 hospitalized. NBC News. November 8, 2019.
Patients at residential care facilities are particularly vulnerable to harm from medication errors. This story highlights a failure that resulted in the misadministration of insulin during a flu vaccination program.

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Cook H, Parson J, Brandt N. J Gerontol Nurs. 2019;45:5-10.
This medical record review study of patients admitted to long-term care following a hospitalization found that medication discrepancies were highly prevalent between the patients' home medication lists, hospital discharge summaries, the electronic health record, and the facility's initial physician order sheet. This work highlights the challenges of accurate medication reconciliation.