Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.
Approach to Improving Safety
Setting of Care
Scrutiny over the quality of care delivered in post-acute settings is catalyzing improvement initiatives for this 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 reported by North Carolina nursing homes to describe specific errors that occurred during patient transitions to nursing homes. Of the nearly 30,000 individual medication errors reported, 11% involved a care transition. Notably, the transition-related errors were also associated with higher odds of patient harm. Contributing factors to the transition-related reports included problems with staff communication, order transcription, medication availability, and pharmacy issues. The authors highlight the opportunities for medication safety during this high-risk transition period for patients.