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

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

September 30, 2015

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

December 9, 2015

An interview with Jerry Gurwitz.

November 29, 2006

Drug shortages and clinicians: no time for complacency.

October 3, 2012

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

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

March 8, 2017

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

March 6, 2005

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

Medication discrepancies upon hospital to skilled nursing facility transitions.

April 29, 2009

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

November 7, 2007

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

August 31, 2011

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

December 7, 2005

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

September 9, 2009

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

April 16, 2008

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

April 15, 2005

The safety of warfarin therapy in the nursing home setting.

June 13, 2007

Communication skills and error in the intensive care unit.

November 28, 2007

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

August 19, 2009

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

November 21, 2012

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

August 7, 2019

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

April 28, 2021

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

February 11, 2009

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

January 14, 2009

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

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

February 23, 2011

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

August 30, 2017

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

Rudeness at work.

July 21, 2010

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

June 27, 2007

Medication errors in the homes of children with chronic conditions.

January 30, 2005

An exploration of safety climate in nursing homes.

August 8, 2012

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

March 6, 2005

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

March 6, 2005

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

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

January 30, 2005

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

November 27, 2013

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

April 7, 2010

Patient safety: helping medical students understand error in healthcare.

August 22, 2007

When the 5 rights go wrong: medication errors from the nursing perspective.

March 10, 2010

Devastatingly human: an analysis of registered nurses' medication error accounts.

June 30, 2010

Making an infusion error: the second victims of infusion therapy-related medication errors.

May 30, 2018

Implementation of the Centers for Medicare & Medicaid Services' nonpayment policy for preventable hospital-acquired conditions in rural and nonrural US hospitals.

October 14, 2015

Hospital staff nurses' shift length associated with safety and quality of care.

April 17, 2013

Medication errors, routines, and differences between perioperative and non-perioperative nurses.

September 12, 2012

More than 1 million potential second victims: how many could nursing education prevent?

June 27, 2018

Influence of socioeconomic bias on emergency medicine resident decision making and patient care.

August 19, 2020

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

Hospital safety climate surveys: measurement issues.

October 20, 2010

Defining attributes of patient safety through a concept analysis.

July 15, 2015

Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.

October 11, 2023

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

June 9, 2010

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

November 29, 2006

Influencing leadership perceptions of patient safety through just culture training.

May 5, 2010

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

October 29, 2014

The working hours of hospital staff nurses and patient safety.

January 9, 2005

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

November 18, 2015

Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.

April 3, 2005

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

April 24, 2013

Variations in nursing care quality across hospitals.

November 4, 2009

Nursing care quality and adverse events in US hospitals.

August 11, 2010

The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.

April 23, 2012

Impact of a pharmacotherapy alerting system on medication errors.

January 23, 2013

Educational levels of hospital nurses and surgical patient mortality.

April 3, 2005

Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.

January 25, 2012

Supplemental nurse staffing in hospitals and quality of care.

August 29, 2007

Error and patient safety: ethical analysis of cases in occupational and physical therapy practice.

March 7, 2007

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

March 9, 2011

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

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

September 21, 2016

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

December 16, 2009

Doctors' handovers in hospitals: a literature review.

March 2, 2011

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

February 29, 2012

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

July 14, 2021

Your company's secret change agents.

May 25, 2005

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

December 11, 2013

Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study.

November 28, 2018

Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study.

January 23, 2013

Nurse staffing, burnout, and health care-associated infection.

August 15, 2012

Parents' perspective on safety in neonatal intensive care: a mixed-methods study.

July 23, 2014

A professional development course improves unprofessional physician behavior.

February 12, 2020

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

November 23, 2005

The variability and quality of medication container labels.

September 19, 2007

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

January 31, 2006

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

November 15, 2017

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.

June 2, 2021

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

March 5, 2008

Are you listening...Are you really listening?

September 17, 2008

Higher quality of care and patient safety associated with better NICU work environments.

September 2, 2015

Temporal clustering of critical illness events on medical wards.

July 26, 2023

Related Resources

Patient Safety Primers

Long-term Care and Patient Safety

April 10, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

October 4, 2023

STOPP/START criteria for potentially inappropriate prescribing in older people: version 3.

September 27, 2023

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

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

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

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

Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.

December 8, 2021

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

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

August 4, 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.

Long-term Care and Patient Safety

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.

Long-term Care and Patient Safety

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

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