Adverse Drug Events in Nursing Homes Are Far More Common Than Previously Identified
"This study confirms that drug-related injuries continue to be a major problem in the long-term care setting," said lead author Jerry H. Gurwitz, MD, the Dr. John Meyers Professor of Primary Care Medicine and professor of medicine and family medicine & community health at the University of Massachusetts Medical School, and the executive director of the Meyers Primary Care Institute, which directed the study. "This makes for a compelling argument for the use of information technology and management systems that can improve communications and decision-making among physicians, nurses and staff, to prevent these kinds of events."
Dr. Gurwitz and a team of physicians and pharmacists reviewed patient records at two large academic long-term care facilities that, combined, had a total of 1229 beds. Researchers looked at patient records covering an 8-month period for one site, and a 9-month period for the other. (December 2000 through July 2001 and December 2000 through August, 2001, respectively) During that time, researchers identified 815 adverse drug events which caused injury to the patient. Of those events, 590 were deemed "less serious", 188 were classified "serious", 33 were called "life-threatening" and four events were fatal. The events were typically caused by errors in drug prescribing and monitoring; these errors included using the wrong dose of a medication, prescribing drugs that interacted with each other, and failing to watch closely for drug side effects. Adverse events were less commonly associated with errors in drug dispensing and administration.
All told, the data translates to a combined rate of nearly 10 adverse drug events per month for every 100 residents of the long-term care facilities. Furthermore, the researchers concluded that 42 % of all the adverse drug events were preventable, and 61% of the serious, life-threatening and fatal adverse events were preventable.
In the study, "less serious" events included skin rashes, falls without associated fracture, bleeding not requiring transfusion or hospitalization, and medication induced drowsiness. More severe events included delirium, falls resulting in fracture, bleeding requiring transfusion, hypoglycemia., and kidney problems.
In 2000, Dr. Gurwitz's team published a similar study which identified adverse drug events in community-based nursing homes. The current study found the rate of adverse drug events was five times higher in the academic facilities than in the community-based nursing homes. An "academic" long-term care facility is differentiated by its affiliation with a medical school and its on-site research and training programs. The higher rates of adverse events at those facilities give researchers reason for concern. "We now believe that our previous studies drastically underestimated the rate of these adverse events in the long-term care setting," said co-author of both studies Terry S. Field, DSc, associate professor of medicine at UMMS and an epidemiologist with the Meyer Primary Care Institute. "The academic centers in our current study are exceptional facilities strongly committed to improving patient care and safety, and with many more resources than community nursing homes. So if we're seeing these rates at these facilities, we believe they must occur at similar or higher rates at most nursing homes in this country."
There are currently 1.6 million people residing in long-term care facilities in the United States. If the findings of the current study are extrapolated and applied to that total population, then one can estimate there are some 1.9 million adverse drug events a year, some 40% of which are preventable, and approximately 86,000 life-threatening or fatal adverse drug events each year in the United States, of which nearly 70% may be preventable. "This seems to be a major safety issue for some of our most vulnerable patients," Dr. Gurwitz said. "We must develop new approaches for making the use of medications less prone to errors and risk for older patients in nursing homes."
In addition to improvements in technology and management systems to deal with the proper ordering and monitoring of medications, Dr. Gurwitz and his team also advocate for increased involvement of relatives of nursing home residents in their care. "In many of our studies, we've seen that it is often a family member who brings attention to a problem with a medication," Dr. Gurwitz said. "So engagement of family members in the care of their older relatives is very important. People should be aware of the drugs that are being prescribed, the reasons for their use, and potential drug side effects; and they should report any changes they notice in their relative's condition."
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The study is reported in "The Incidence of Adverse Drug Events in Two Large Academic Long-term Care Facilities" by Jerry H. Gurwitz, MD, Terry S. Field, DSc, James Judge, MD, Paula Rochon, MD, MPH, Leslie R. Harrold, MD, MPH, Cynthia Cadoret, Monica Lee, RPh, Kathleen White, RPh, Jane LaPrino, Janet Erramuspe-Mainard, Martin DeFlorio, RPh and Linda Gavendo, RPh, Jill Auger, RPh, David W. Bates, MD, MSc. The article appears in The American Journal of Medicine, Volume 118, Number 3 (March 2005), published by Elsevier.
Full text of the article mentioned above is available upon request. Contact ajmmedia@elsevier.com to obtain a copy or to schedule an interview.
© 2005 The American Journal of Medicine. All rights reserved. Unauthorized use prohibited.
The American Journal of Medicine (http://www.ajmselect.com), known as the "Green Journal," is one of the oldest and most prestigious general internal medicine journals published in the United States, as evidenced by its 2003 Impact Factor of 4.403 (Source: Journal Citation Reports). The American Journal of Medicine, the official journal of The Association of Professors of Medicine, a group comprised of chairs of departments of internal medicine at 125-plus U.S. medical schools, publishes peer-reviewed, original scientific studies that have direct clinical significance. The information contained in this article in The American Journal of Medicine is not a substitute for medical advice or treatment, and the Journal recommends consultation with your physician or healthcare professional. The Journal is published by Elsevier (http://www.elsevier.com), a leading global publisher of scientific, technical, and medical journals, books, and reference works. It is a member of the Reed Elsevier plc group.
The Meyers Primary Care Institute is a joint endeavor of the University of Massachusetts Medical School, the Fallon Foundation, and the Fallon Community Health Plan, with a mission to promote primary care research and education. The Fallon Foundation is a non-profit, charitable organization dedicated to serving its communities through health promotion, public education in health maintenance and disease prevention, and provision of health-care services. For more information go to: http://www.umassmed.edu/meyers.
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