Patient Safety Tip of the Week

January 18, 2011

More on Medication Errors in Long-Term Care


So you work in an acute care hospital, not a long-term care (LTC) facility – don’t stop reading!!! You’ll see that you may be responsible for many of the medication errors that occur at LTC facilities.


We did a pretty thorough review on this topic in our July 21, 2009 Patient Safety Tip of the Week “Medication Errors in Long-Term Care” but are always happy to do updates when new information becomes available.


ISMP Canada recently reported on a 9-year experience with incidents in long-term care settings in their medication incident reporting database (ISMP Canada 2010). That database contained almost 5000 incidents in long-term care (probably a considerable underreporting) and they found harm or death occurred in 2.8%. When they analyzed the cases with harm or death, 3 main themes arose:

  • High-alert medications
  • Sedatives, anxiolytics, antipsychotic drugs and falls
  • Transitions of care


The “big three” high-alert medications involved in incidents in LTC were anticoagulants, insulin, and opioids. Most of the anticoagulant incidents involved errors in monitoring patients on warfarin therapy. The insulin errors were similar to those that we see in acute care (see our November 2, 2010 Patient Safety Tip of the Week “Insulin: Truly a High-Risk Medication”). The opioid incidents were interesting in that one of the top four opioid incident themes related to Fentanyl patches. The latter included cases where the wrong dose Fentanyl patch was applied and cases where old Fentanyl patches were not removed when new ones were applied, resulting in multiple Fentanyl patches releasing drug into the patient’s system. Note that ISMP Canada had previously done a safety bulletin on incidents involving Fentanyl patches in multiple settings (ISMP Canada 2009).


The incidents related to anxiolytic-sedative medications or antipsychotic medications most often resulted in falls. The falls typically occur in patients who get drowsy or confused on these medications, though some may also cause orthostatic hypotension as a potential cause for falls.


And, of course, LTC patients are particularly prone to errors in transitions of care since (a) they are generally admitted from an acute care facility and (b) they often require transfers to and from acute care hospitals. But there are also several other factors that predispose LTC patients to medication errors during such transitions of care. One is that when a patient is transferred from an acute care hospital to a LTC facility, the orders are often either (a) faxed or (b) photocopied (c) carbon-copied or (d) verbal, all being error-prone methods.


We previously have discussed how decimal points may be obscured in orders that are fax copies or carbon copies or photocopies (see our March 12, 2007 Patient Safety Tip of the Week “10x Overdoses”). We also previously noted a case where medication lists from an SNF on two separate patients were faxed to an acute hospital at the same time. As a result, one patient was actually begun on all his own medications plus those intended for the second patient. Several days went by before the error was recognized. A recent ISMP Medication Safety Alert (ISMP 2010) pointed out the opposite problem: multiple pages may be pulled through the scanner or fax machine at the same time (causing a whole sheet to be missed), resulting in omission of multiple drugs for a patient. You need to have strict policies and procedures that require all received fax materials clearly state the patient’s name and other identifiers on each page and that each batch of faxed materials have a cover sheet which tells you how many pages to expect. If the expected number of pages is not received do not accept the fax. Contact the party doing the faxing and ask them to resend.


In our July 21, 2009 Patient Safety Tip of the Week “Medication Errors in Long-Term Care” we cited a study (Tjia et al 2009) looking at medication discrepancies in patients transitioning from acute hospitals to long-term care facilities that found at least one medication discrepancy occurred in 71.4% of admissions to the SNF and in 21.3% of all medications. Also the discharge summary and the patient care referral form did not match in 52.3% of cases. Moreover, there is often a delay in medication administration for those SNF patients transferred from acute care facilities, especially those transferred in the evening.


But another factor that we’d think would protect against errors may also actually contribute to errors in some cases: familiarity with the patient. The ISMP Canada Safety Bulletin provides an example where a nurse in an LTC facility, upon transfer of a patient back from an acute care hospital, miscopied a medication dosage from faxed materials. When staff called the physician for orders, the physician (who had known the patient previously and had followed the resident in the acute hospital) simply instructed the staff to “continue the same orders”.


Some LTC facilities do not have their own pharmacies so rely on outside sources for their medication supplies. Often they have multiple different sources and their access to some medications may not be immediate (Stefanacci 2008).


It is often difficult to get a handle on the frequency of medication errors in LTC because the data sources are often not reporting the same metrics. SNF’s commonly report on errors during the medication administration phase. Therefore, things like wrong dose, dose omission, wrong time, wrong patient, etc. tend to show up frequently in statistics. The IOM report “Preventing Medication Errors” notes the rate of medication administration errors in SNF’s to range from 6 to 20 per 100 opportunities/doses. Wrong-time errors are particularly common in LTC facilities. Stefanacci (Stefanacci 2008) notes that a typical “med pass” in a LTC facility lasts over 2 hours so that it may be almost impossible for a nurse to administer all medications within 1 hour of scheduled time.


But some more prospective studies have demonstrated that errors in the ordering and monitoring stages are equally important, and those are often not reported in the LTC incident databases. Errors in the monitoring stage are particularly common causes of preventable adverse drug events in LTC facilities (Gurwitz 2005).


The IOM report also discusses underutilization of medications in the LTC population. They cite failure to use ACE inhibitors in CHF patients, aspirin and beta blockers in post-MI patients, antiplatelet agents in post-stroke patients, calcium supplements in patients with osteoporosis and others as common in LTC populations. There are some drugs, most notably warfarin in patients with atrial fibrillation, that are often not prescribed in the elderly because they are “too risky” despite evidence that the risk:benefit ratio may actually be better in some elderly patients.


Overutilization also occurs. You’ve heard us on multiple occasions discuss the problem of patients being started on a proton-pump inhibitor or H2-blocker prophylactically while acutely ill in an ICU but never having those drugs discontinued, including after discharge. We actually recommend that every LTC facility, on receiving a patient from an acute care facility, specifically question the appropriateness of either of those drug categories.


Many of the technological interventions to reduce medication errors and adverse drug events, such as computerized physician order entry (CPOE), bedside medication verification (barcoding), and clinical decision support tools have not yet been widely implemented in LTC settings. Even where they have been implemented, dangerous workarounds have occurred more frequently in LTC/SNF settings than in acute care settings (Patterson 2006). But the good news is that some IT solutions have been successful in the LTC setting. Computerized alerts for renal dosing in a LTC setting (Field et al 2009) 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).


We’ve done several columns regarding use of Beers’ List, Medication Therapy Management (MTM) programs, the Good Palliative-Geriatric Practice (GP-GP) algorithm, etc. in helping manage medications in the elderly. Most of those can be accessed via our October 19, 2010 Patient Safety Tip of the Week “Optimizing Medications in the Elderly”. While these are often applied to community-based populations, there is no reason they should not be being applied to the elderly in LTC settings as well.


Fortunately, there are some great tools out there to help you develop your medication safety programs in the LTC setting. The Massachusetts Coalition for the Prevention of Medical Errors developed a 200-page workbook for reduction of medication errors in long-term care. This is a comprehensive resource that takes you all the way from developing a culture of safety, educating staff, through setting up policies and procedures for medication management, and implementing quality improvement programs to monitor progress and improve. 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.



So what should you be doing to reduce the occurrence of medication errors in LTC?

  • Work with all your referral sources to optimize medication reconciliation.
  • Have policies and procedures on acceptance of faxed records that minimize the risk of errors.
  • Maintain a list of medications that are often inappropriately continued after discharge from acute care (eg. proton pump inhibitors, H2-blockers, etc.) that should trigger an automatic call for verification.
  • Implement CPOE with clinical decision support, bedside medication verification (barcoding), and participate in HIE’s (health information exchanges) which share medical data from multiple sources.
  • Utilize tools like Beers’ List, Medication Therapy Management (MTM) programs, the Good Palliative-Geriatric Practice (GP-GP) algorithm, etc. to better manage medications in the elderly.
  • Use tools like the Massachusetts “A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook” or participate in programs like ISMP Canada’s Medication Safety Self-Assessment® for Long-Term Care program.



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. As CMS and other payors switch to new reimbursement methodologies intended to reduce unnecessary admissions and readmissions to acute care hospitals, it becomes increasingly important for acute care facilities to work closely with LTC facilities to minimize the medication errors that often lead to avoidable hospitalizations.







ISMP Canada. Medication Incidents Occurring in Long-Term Care. ISMP Canada Safety Bulletin 2010; 10(9): 1-3 December 10, 2010



ISMP Canada. Analysis of International Findings from Incidents Involving Fentanyl Transdermal Patches. ISMP Canada Safety Bulletin 2009; 10: 1-2 (December 30, 2009)



ISMP (Institute for Safe Medication Practices). Order scanning systems (and fax machines) may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety Alert (Nurse Advise-ERR) 2010; 8(11):  1-2



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



Stefanacci RG (Spivack BS Series Editor). Preventing Medication Errors. Annals of Long Term Care 2008; 9/5/2008



IOM (Institute of Medicine). Institute of Medicine Report: Preventing Medication Errors. July 2006.



IOM (Institute of Medicine). Incidence Of Medication Errors In Nursing Homes. In Institute of Medicine Report: Preventing Medication Errors. July 2006.



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



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



Field TS, Rochon P, Lee M, et al. Computerized Clinical Decision Support During Medication Ordering for Long-term Care Residents with Renal Insufficiency.

JAMIA 2009; 16: 480-485



Massachusetts Coalition for the Prevention of Medical Errors.



MASSPRO, The Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Federation, Betsy Lehman Center for

Patient Safety and Medical Error Reduction and the Massachusetts Department of Public Health. A Systems Approach to Quality Improvement in Long-Term Care:

Safe Medication Practices Workbook. 2005



ISMP Canada. Medication Safety Self-Assessment® for Long-Term Care.
















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