Patient Safety Tip of the Week


July 21, 2009        Medication Errors in Long-Term Care





Medication errors in long-term care (LTC) or skilled nursing facilities (SNF) are just as frequent as in acute hospitals. And the elderly patient population cared for at most long-term care facilities are particularly vulnerable to the adverse effects of medication errors. A variety of factors contribute to this vulnerability. First and foremost, they tend to be on larger numbers of medication, increasing the likelihood of drug-drug interactions and increasing the likelihood of additive effects of side effects. Both renal and hepatic function tend to decline in the aging population, interfering with clearance of many drugs. Impaired ability to chew or swallow may necessitate changes in the usual manner of medication administration. The elderly, particularly those with pre-existing dementia, tend to have a reduced “cognitive reserve” that may increase their likelihood of developing delirium when subject to certain drugs and other agents. And the cognitive impairment plus impaired vision or hearing may also prevent the patient himself from acting as a last-line defense against a medication error. The patient in SNF/LTC also receives much less direct attention from physicians and other medical professionals than do patients in acute care facilities. The provider ordering medications is often not even present at the SNF/LTC at the time the medication is ordered (i.e. the order is often entered remotely or called in by telephone). And often the nurse dispensing medications has multiple other duties and responsibilities that may lead to distractions and interruptions in the medication dispensing/administration stages. Undoubtedly, if one does thorough root cause analyses we would see workload, staffing, continuity and staff turnover issues as important root causes.


Gurwitz et al 2000 studied 18 community-based nursing homes and found a rate of adverse drug events of 1.89 per 100 resident months (plus another 0.65 per 100 resident-months of potentially adverse drug events). Many of these were potentially life-threatening or serious. And, most importantly, over 50% were considered to be potentially preventable. In fact, 72% of the more serious adverse events were potentially preventable. Gurwitz et al 2005 looked at adverse drug events in 2 academic LTC facilities and found an even higher rate of ADE’s (9.8 per 100 resident-months). Again, 42% of these were potentially preventable. The authors attributed the much higher rate in the second study to better and multiple methods for detecting adverse drug events. In both studies, most of the errors tended to occur in the stages of ordering and monitoring. Several drug categories were overrepresented: antipscyhotic medications, anticoagulants, diuretics, and antiepileptic medications.


But acute care hospitals may play a role in the medication errors that occur in LTC facilities. We’ve written a lot recently about the problem of Medicare readmissions. Readmissions from long-term care facilities are especially problematic for some acute care facilities. And many of these are related to medication errors and adverse medication events. Sometimes the acute care facility actually contributes to such errors. A recent study (Tjia et al 2009) looked at medication discrepancies in patients transitioning from acute hospitals to long-term care facilities (skilled nursing facilities or SNF’s). At least one medication discrepancy occurred in a whopping 71.4% of admissions to the SNF and in 21.3% of all medications. The discharge summary and the patient care referral form did not match in 52.3% of cases. In addition, there is often a delay in medication administration for those SNF patients transferred from acute care facilities, especially those transferred in the evening. One pilot study (Ward et al 2008) showed the mean delay from arrival in dose of an ordered medication was 12.55 hours and the mean number of omitted medications was 3.4.


On top of that are those cases where medication reconciliation on discharge from the acute facility is faulty and patients are inadvertently continued on medications (eg. proton pump inhibitors) that had been intended as prophylaxis only for a limited time while that patient had been acutely ill.


Very few SNF/LTC facilities have CPOE (computerized physician order entry), one useful mechanism to reduce medication errors. However, most do have pharmacy order systems that have the capability to set up alerts based on “rules”. So, for the example given above, a rule could be programmed that says “if a drug in the proton pump inhibitor class is prescribed and was not on the prior medication list, then check with the attending physician to confirm its necessity”.


All the other types of medication errors we see in acute care also occur in chronic care. We’ve emphasized the problem of workarounds with barcoding bedside medication verification systems (see our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent”). One study (Patterson et al 2006) showed that such workarounds occur significantly more frequently in LTC/SNF than in the acute care hospital. And, just as we have learned with CPOE in acute care and ambulatory care, physicians ignore the vast majority of alerts and reminders triggered during order entry. A study in a LTC facility (Judge et al 2006) showed that prescribers who received an alert were only about 10% more likely to take an appropriate action, though responses were higher for anticoagulant or CNS side effect warnings. Errors due to look-alike/sound-alike (LASA) drug pairs also obviously occur in the SNF/LTC setting (Walliser et al 2007). Errors in repackaging of medications (Gerber et al 2008) are also common. That study, done in LTC facilities in Germany where repackaged medications for each patient are put in pill organizers containing the entire day’s medications, showed errors in 7.3% of all pill organizers and affecting over half of LTC residents. Incorrect halving of the medications was the most frequent error encountered.


Medication errors related to administration of medications may occur despite good automated dispensing processes. One study (van den Bemt et al 2009), using a disguised observation technique, found errors in 21.2% of all observed medication administrations in 3 SNF’s. Administration technique errors such as those related to medication crushing were the most common errors identified. But lack of supervision of intake by the patient was also frequent. Wrong time of medication administration was particularly relevant for those medications supposed to be taken in relationship to meals.


ISMP Canada’s Medication Safety Self-Assessment (MSSA) program administers the assessment across all levels of the healthcare continuum. The tool is administered via secure internet access and for LTC facilities consists of 125 items by which LTC facilities assess their relative performance in medication safety. Though still in its infancy, the program has identified both strengths and weaknesses in medication safety systems in LTC facilities. On the positive side, LTC facilities tend to use computerized pharmacy information systems with resident medication profiles, have allergies listed on each page of the MAR, dispense by unit dose, use patient photographs to assist in correct patient identification, have standardized administration times, and have pharmacists available to work with care teams. But areas they have identified as being in need of improvement are: dealing with high-alert medications, minimizing interruptions during the medication administration processes, lack of CPOE/clinical decision support systems, use of dangerous abbreviations, and relative lack of use of patient safety learning tools.


Another study from Canada just published (Field et al 2009) looked at computerized alerts for renal dosing in a LTC setting. This was a randomized controlled trial in which the prescribing physician saw the alerts in the intervention arm and did not see them in the control arm. The alerts were successful for reducing the maximum frequency of medications, avoiding medications that should be avoided, and supplying missing information (such as a current creatinine level).


The bottom line is that we have a whole lot of opportunities to improve medication safety in the LTC/SNF setting and especially to improve our coordination of care between the LTC/SNF and acute care settings. Particularly when CMS initiates its new focus on reducing readmissions to acute care, increased collaboration between the acute and chronic settings to reduce adverse drug events will be crucial.




Update: See our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care”.







Gurwitz JH, Field TS, Avorn J et al. Incidence and preventability of adverse drug events in nursing homes. American Journal of Medicine 2000; 109: 87-94



Gurwitz JH. Field TS. Rochon JJ et al. The incidence of adverse drug events in two large academic long-term care facilities. American Journal of Medicine 2005; 118(3):251-8



Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med. 2009; 24:630-635



Ward KT, Bates-Jensen B, Eslami MS et al. Addressing delays in medication administration for patients transferred from the hospital to the nursing home: A pilot quality improvement project. American Journal Geriatric Pharmacotherapy 2008; 6(4):205-211



Patterson ES. Rogers ML. Chapman RJ. Render ML. Compliance with intended use of Bar Code Medication Administration in acute and long-term care: an observational study.

Human Factors 2006;. 48(1):15-22



Judge J, Field TS, DeFlorio M. et al. Prescribers' responses to alerts during medication ordering in the long term care setting. Journal of the American Medical Informatics Association 2006; 13(4):385-90



Walliser G, Grossberg R, Reed MD. Look-alike medications: a formula for possible morbidity and mortality in the long-term care facility. Journal of the American Medical Directors Association 2007; 8(8):541-2



Gerber A, Kohaupt I, Lauterbach KW et al. Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany.

American Journal Geriatric Pharmacotherapy 2008; 6(4):212-9



van den Bemt PMLA, Idzinga JC, Robertz H, Kormelink DG, Pels N. Medication Administration Errors in Nursing Homes Using an Automated Medication Dispensing System. J Am Med Inform Assoc 2009; 16: 486-492.



ISMP Canada. Medication Reconciliation and Medication Review:

Complementary Processes for Medication Safety in Long-Term Care. ISMP Canada Safety Bulletin 2008; 8: 1-3



Field TS, Rochon P, Lee M et al. Computerized Clinical Decision Support During Medication Ordering for Long-term Care Residents with Renal Insufficiency. J Am Med Inform Assoc 2009; 16: 480-485.








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