Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Active Errors"

1 - 20 of 62 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Study

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017 May 19; [Epub ahead of print].

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

Journal Article > Commentary

Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.

Carroll C, Hassanin A. JAMA Intern Med. 2017 Apr 24; [Epub ahead of print].

Geriatric patients are particularly vulnerable to adverse drug events due to comorbidities, complicated care plans, and polypharmacy. This commentary describes how using STOPP criteria and performing indication mapping can help reduce polypharmacy and improve patient safety.

Tools/Toolkit > Fact Sheet/FAQs

Four Medication Safety Tips for Older Adults.

FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; September 20, 2016.

Highlighting how aging affects medication absorption that may lead to complications, this fact sheet offers recommendations for older patients to follow instructions, maintain a medication list, be aware of drug interaction potential, and perform an annual review of medications with clinicians to help them take prescriptions safely.

Cases & Commentaries

A Pill Organizing Plight

  • Spotlight Case
  • CME/CEU
  • Web M&M

Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016

An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.

Journal Article > Study

Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study.

van Welie S, Wijma L, Beerden T, van Doormaal J, Taxis K. BMJ Open. 2016;6:e012286.

Not all pill-form medications can be safely crushed to administer to patients who have difficulty swallowing. In this before and after intervention study in a nursing home, adding warning symbols and educating staff about crushing medications led to a decrease in pill-crushing errors. The authors conclude that education and warnings enhanced this aspect of medication safety.

Journal Article > Commentary

Preventing medication errors.

Stefanacci RG, Riddle A. Geriatr Nurs. 2016;37:307-310.

Nursing home patients are particularly vulnerable to medication errors. This commentary describes an incident involving a medication error and reviews conditions in long-term care that increase the potential for similar errors to occur. The authors suggest that proactive system improvements must address weaknesses in ordering, administration, compliance, and medication reconciliation.

Journal Article > Study

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial.

Bhattacharya D, Aldus CF, Barton G, et al. Health Technol Assess. 2016;20:1-250.

Medication organization devices provide compartments to help sort patients' medications by days of the week and are thought to improve medication safety. Assessing patients age 75 and older who were prescribed three or more oral medications, this feasibility study found that medication adherence did not improve among those given medication organization devices compared to those using standard medication dispensing. The authors note that many potentially eligible participants were excluded because they already used such devices and suggest that future studies target a younger age range.

Cases & Commentaries

Mismanagement of Delirium

  • Web M&M

Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS; May 2016

An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.

Journal Article > Commentary

Among the elderly, many mental illnesses go undiagnosed.

Bor JS. Health Aff (Millwood). 2015;34:727-731.

This commentary spotlights missed and delayed diagnosis of psychiatric conditions in older patients. The authors explore how insufficient physician experience with mental illness in geriatric patients, patient reluctance to discuss emotional challenges, and comorbidities with physical problems can contribute to errors.

Journal Article > Study

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.

O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. Age Ageing. 2015;44:213-218.

This consensus guideline describes expanded criteria to identify inappropriate medication prescribing for older patients. This strategy can address high rates of adverse drug events in older populations, especially if integrated into clinical decision support.

Audiovisual > Audiovisual Presentation

Applying High Reliability Principles to Infection Prevention and Control in Long Term Care.

Oakbrook Terrace, IL: Joint Commission; 2014.

Safety problems, particularly medication errors and poor hand hygiene compliance, are common in nursing homes. This Web site offers an online learning module and related information about how to apply high reliability concepts to reduce health care–associated infections in long-term care settings.

Journal Article > Study

Antibiotic prescribing practice in residential aged care facilities—health care providers' perspectives.

Lim CJ, Kwong MWL, Stuart RL, et al. Med J Aust. 2014;201:101-105.

This qualitative study explored barriers to appropriate antibiotic use in residential aged care facilities in Australia. Several organizational and cultural issues emerged, including inadequate staffing of on-site physicians which placed the burden of infection diagnosis and management on nurses not sufficiently trained to perform this role.

Journal Article > Study

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.

Lee A, Mills PD, Neily J, Hemphill RR. Jt Comm J Qual Patient Saf. 2014;40:253-262.

This chart review study analyzed information from the Veterans Health Administration national database of root cause analyses to describe adverse events among veterans aged 65 years and older that resulted in sustained injury or death. Frequent incidents were falls, delays in diagnosis or treatment, and medication errors. Inadequate communication was the most common root cause identified in adverse events, and within this category, poor communication among providers (such as handoffs) often resulted in adverse events. Although virtually all root cause analyses led to implementation of action plans, only 40% were deemed effective. Compared to previous research, this study highlights robust use of root cause analysis while emphasizing the need for ongoing monitoring and improvement of corrective actions.

Cases & Commentaries

Medication Reconciliation With a Twist (or Dare We Say, a Patch?)

  • Spotlight Case
  • Web M&M

Janice L. Kwan, MD; May 2014

An elderly woman with a history of dementia underwent surgical resection of new colon cancer, which relieved a bowel obstruction. She developed acute delirium postoperatively, and the team discovered they had neglected to capture her cholinesterase inhibitor patch (a medication for dementia) in the official medication reconciliation list.

Journal Article > Study

Characteristics of patients misdiagnosed with Alzheimer's disease and their medication use: an analysis of the NACC-UDS database.

Gaugler JE, Ascher-Svanum H, Roth DL, Fafowora T, Siderowf A, Beach TG. BMC Geriatr. 2013;13:137.

Using autopsy results, this study found that patients misdiagnosed with Alzheimer disease were more likely to be older, live alone, and have cardiovascular conditions, compared to accurately diagnosed individuals. Many misdiagnosed patients were taking inappropriate medications, which can have significant clinical and financial ramifications.

Cases & Commentaries

SNFs: Opening the Black Box

  • Web M&M

Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP; December 2013

Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.

ISMP Long-Term Care Advise-ERR.

Institute for Safe Medication Practices. 200 Lakeside Drive, Suite 200; Horsham, PA 19044.

This newsletter focuses on medication safety concerns that administrators, nurses, and other health care workers may encounter while providing long-term care services.

Journal Article > Study

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.

Desai RJ, Williams CE, Greene SB, Pierson S, Hansen RA. J Healthc Risk Manag. 2013;33:33-43.

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.

Journal Article > Commentary

Reducing the risk of adverse drug events in older adults.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Am Fam Physician. 2013;87:331-336.

This commentary outlines types of adverse drug events that occur in elderly patients and recommends prevention strategies, including the Beers criteria and STOPP criteria.

Perspectives on Safety > Interview

In Conversation With… Beverley H. Johnson

Engaging the Patient and Family in Safety, February 2013

Beverley Johnson is President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care.

Back to Top