Serious Outcomes from Medication Errors in Nursing Homes May be Rare


Up to 1% of all medication errors in nursing homes result in serious outcomes.

Findings from a new study suggest that medication errors occurring in nursing homes do not typically result in serious complications.

In some cases, medication errors can result in significant harm, especially in older adults living in nursing homes, who may rely on other individuals to receive the proper medication.

In a study published by the Journal of the American Geriatrics Society, researchers conducted a literature review of studies published between 2000 and 2015 to determine factors linked to, and the prevalence of, medication errors that lead to hospitalizations and deaths among these patients.

The researchers included 11 relevant studies in their review, and examined 3 different types of errors: all medication errors, transfer-related medication errors, and potentially inappropriate medications.

Researchers discovered that medication errors in nursing homes were quite common. In examining all types of medication errors, they occurred in 16% to 27% of all residents included in the respective studies. They also found that 13% to 31% of residents included experienced a transfer-related medication error, according to the study.

Surprisingly, 75% of the patients included in the studies had been prescribed at least 1 potentially inappropriate medication.

However, serious outcomes from these errors were very low. Only 0% to 1% of medication errors result in serious complications, and death from these errors was even rarer, according to the study.

These findings suggest that medication errors may not result in serious outcomes a majority of the time, but the researchers noted that their findings do not clearly point to this.

Due to the difficulty in ascertaining serious outcomes related to medication errors, these adverse events may be under-reported rather than not happening, according to the study. Additional studies are needed to determine whether these events do not occur, or there are reporting errors.

Although the instances of death and serious adverse events may be rare, this issue still needs to be addressed by healthcare professionals. One way to do so is to implement a medication reconciliation program, which evaluates a complete list of medications used by each patient.

The main goal of these programs is to create an accurate list of administered medications, and eliminate any potentially harmful discrepancies. This reduces the likelihood of being prescribed a potentially inappropriate medication that can lead to adverse events.

Long-term care facilities also should train their staff more extensively to prevent these errors from occurring.

“This is an important step to addressing the global issue for improving the quality and safety of medications for older people,” said lead researcher Joseph Ibrahim, MBBS, FRACP, PhD. “Nursing homes should review their systems of care from prescribing to administration. Good practice requires using a team-based approach involving the resident, care and nursing staff, pharmacists, and medical practitioners.”

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