Tuesday, 22 November 2016

SPHPM study of global medication errors in nursing homes reveals surprising results


Professor Joseph Ibrahim from SPHPM’s Department of Forensic Medicine (DOFM), with other researchers, has conducted a unique review of international data to determine the prevalence of medication errors in nursing homes, globally, leading to hospitalisation or death.

The paper, “A systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents’, published in the Journal of the American Geriatrics Society revealed low rates of serious impacts from medication errors affecting nursing home residents, despite the fact that these errors remain fairly common.


The study looked at all research into medication errors in nursing homes from 2000 to 2015 in English, French, German or Spanish publications.

Professor Ibrahim said that it is unclear whether medication errors resulting in serious outcomes are truly infrequent or are under-reported due to the difficulty in ascertaining them.

“We expected a higher proportion of harm from medication use because older people in nursing homes are usually taking multiple medicines, are frail, have multiple diseases and a reduced ability to recover for any injury.

“Each of these factors increases the risk of harm. We thought that when all of these factors combined, this would magnify the risk of hospitalisation and death greatly,” said Professor Ibrahim.


The review found that medication errors:

  • Occur in up to 27 per cent of residents;
  • Up to 31 per cent of patients received the wrong medication as a result of being transferred to another facility such as a hospital from a nursing home;
  • 75 per cent of nursing home residents received at least one potentially inappropriate medication (PIM), that is medicines that are prescribed but may not be necessary for the resident; and
  • On average up to 15 per cent of medication errors in nursing homes led to harm, according to the review, but a “small proportion” led to permanent disability or death.  

The review also found that the most frequent error was a resident being given the wrong dosage due to dose calculation, illegible orders, altering dose forms and failure to adjust dose during monitoring. The drugs most likely to be given incorrectly were warfarin and antipsychotics.

There was no clear pattern in relation to which nursing home staff were involved in medication errors.  Also, given that death in this group is often not unexpected, it is possible that fatal errors may go unreported.

“This is an important step to addressing the global issue for improving the quality and safety of medications for older people.

“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,” said Professor Ibrahim.

DOFM is undertaking further research in the field with ongoing research looking at Coroners Cases of deaths from medication - it is anticipated that this will be completed mid-2017.



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