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- Communication Improvement 8
- Education and Training 3
- Error Reporting and Analysis 1
- Legal and Policy Approaches 8
- Quality Improvement Strategies 4
- Technologic Approaches 2
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 9
- Overtreatment 1
- Psychological and Social Complications 1
Search results for "Geriatrics"
Tools/Toolkit > Fact Sheet/FAQs
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.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
Journal Article > Study
Heyland DK, Barwich D, Pichora D, et al; ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET). JAMA Intern Med. 2013;173:778-787.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Web Resource > Database/Directory
Centers for Medicare and Medicaid Services.
This website provides consumers with detailed information about the past performance of every Medicare- and Medicaid-certified nursing home in the country. Additional resources available at the site help with other nursing home selection issues. Information is provided in English, Spanish, and Chinese.
Boodman SG. Washington Post. December 9, 2017.
The prevalence of polypharmacy among older patients represents an important concern for health care safety, as unneeded medications can contribute to patient harm. This newspaper article reports on several strategies to reduce inappropriate medication use in older patients, including desprescribing and brown bag medication review.
Cases & Commentaries
- Spotlight Case
- 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.
Gorman A. Kaiser Health News. August 30, 2016.
Older patients are particularly vulnerable to medication errors, as they are often prescribed multiple medications for chronic conditions. This news article reports on complexities associated with managing medications in older patients, including how miscommunication between care team members and patient misunderstanding of postdischarge medication changes can increase risks and contribute to preventable harm. A recent WebM&M commentary discussed strategies to safely manage medications in older patients and highlighted the importance of medication reconciliation.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Ornstein C. Washington Post. July 12, 2015.
Anticoagulants are considered high-alert medications that if used ineffectively can result in patient harm. Reporting on an anticoagulant commonly used in nursing homes and patient harm linked to this medication, this newspaper article relates reasons doctors are reluctant to prescribe new drugs to older patients and challenges to monitoring and preventing such adverse drug events.
Pierrotti A. USA Today. August 18, 2014.
Jones R. WXYZ. November 13, 2013.
This news piece reports on risks associated with medication delivery in nursing homes and reveals several incidents that resulted in significant patient harm.
Ackerman T. Houston Chronicle. November 23, 2012.
This newspaper article describes challenges that may precipitate underdiagnosis or misdiagnosis of Alzheimer disease and conditions with similar presenting symptoms.
Agnvall E. AARP. November 16, 2012.
Greider K. AARP Bulletin. March 2012;53:10,12,14.
Graham J. Los Angeles Times. May 11, 2011.
This newspaper article reports on common errors that may occur during hospitalization and offers tips for patients to participate in their safety.
Haiken M. Caring.com. August 17, 2009.
To help consumers use medications safely, this article describes 10 common medication mistakes and provides tips on how effective communication and clarification can prevent them.
Cohen E. Empowered Patient. CNN.com. May 29, 2008.
This news article and accompanying video highlight problems associated with polypharmacy in elderly patients.
Cooney E. Worcester Telegram & Gazette. January 28, 2008;Living section:E1.
This article discusses an AHRQ-funded program to study information technology tools and their ability to minimize medication errors in a geriatric patient population.
Dembner A. Boston Globe. July 3, 2006;Health Science section:A1.
This article reports on the movement to improve care in nursing homes in order to decrease unnecessary hospitalizations for elderly patients.
Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth B. Lamont, MD, MS; September 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.