Medication errors in nursing homes: Incidence and reduction strategies

Journal of Pharmaceutical Finance, Economics and Policy

Volumn 16, Issue 1, 2008, Pages 5-133

  Pepper, Ginette A ^a   Towsley, Gail L ^a  

^a UNIVERSITY OF UTAH   (United States)

Author keywords

Administration error; Adverse drug events; Assisted living facilities; Dispensing error; Inappropriate prescription; Long term care; Medication error; Nursing homes; Prescribing error

Indexed keywords

ANALGESIC AGENT; ANTIBIOTIC AGENT; ANTICONVULSIVE AGENT; ANTIDEPRESSANT AGENT; ANTIULCER AGENT; ANXIOLYTIC AGENT; BENZODIAZEPINE DERIVATIVE; COTRIMOXAZOLE; DEXTROPROPOXYPHENE; DIGOXIN; DIPYRIDAMOLE; DIURETIC AGENT; DOXEPIN; GASTROINTESTINAL AGENT; HISTAMINE H2 RECEPTOR ANTAGONIST; HYPNOTIC AGENT; HYPNOTIC SEDATIVE AGENT; INSULIN; IRON; LOOP DIURETIC AGENT; MULTIVITAMIN; NEUROLEPTIC AGENT; NONSTEROID ANTIINFLAMMATORY AGENT; OXYBUTYNIN; POTASSIUM; PSYCHOTROPIC AGENT; THEOPHYLLINE; THYROID HORMONE; TICLOPIDINE; UNINDEXED DRUG;

ADVERSE DRUG REACTION; ARTICLE; CLINICAL PRACTICE; CONTINUING EDUCATION; CORRELATION ANALYSIS; DEATH; DISEASE SEVERITY; DRUG INDICATION; DRUG PACKAGING; DRUG USE; FALLING; GOOD CLINICAL PRACTICE; HEALTH CARE QUALITY; HIGH RISK POPULATION; HOSPITALIZATION; HUMAN; INCIDENCE; MEDICAL DOCUMENTATION; MEDICAL EDUCATION; MEDICAL LITERATURE; MEDICATION ERROR; NURSING HOME; NURSING HOME PATIENT; OUTCOMES RESEARCH; PAIN; PATIENT TRANSPORT; POLYPHARMACY; PRESCRIPTION; PRIORITY JOURNAL; PUBLICATION; RISK ASSESSMENT; RISK FACTOR; RISK REDUCTION; SIDE EFFECT; STANDARD;

EID: 38049080019     PISSN: 15385698     EISSN: 15385396     Source Type: Journal    
DOI: 10.1300/J371v16n01_03     Document Type: Article

References (123)

1. Allard, J., Hebert, R., Rioux, M., Asselin, J., & Voyer, L. (2001). Efficacy of a clinical medication review on the number of potentially inappropriate prescriptions prescribed for community-dwelling elderly people. Canadian Medical Association Journal, 164, 1291-1296.
2. American Geriatrics Society. (2002). The management of persistent pain in older persons. Journal of the American Geriatrics Society, 50, S205-S224.
3. Avorn, J. & Gurwitz, J. H. (1995). Drug use in the nursing home. Annals of Internal Medicine, 123(3), 195-204.
4. Avorn, J. & Soumerai, S. B. (1983). Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically-based "detailing." New England Journal of Medicine, 308(4), 1457-1463.
5. Avorn, J., Soumerai, S., Everitt, D. E., & Al, E. (1992). A randomized trial of a program to reduce the use of pyschoactive drugs in nursing homes. New England Journal of Medicine, 327, 168-173.
6. Baldwin, V. R. (1992). An analysis of subjective and objective indicators of quality of care in North Carolina homes for the aged. Dissertation Abstracts Online.
7. Barker, K. N., Flynn, E. A., Pepper, G. A., Bates, D. W., & Mikeal, R. L. (2002a). Medication errors observed in 36 health care facilities. Archives of Internal Medicine, 162(16), 1897-1903.
8. Barker, K. N., Flynn, E. A., Pepper, G. A., Bates, D. W., & Mikeal, R. L. (2002b). Comparison of three methods of detecting medication administration errors. American Journal of Health Systems Pharmacy, 59(5), 436-446.
9. Barker, K. N., Mikeal, R. L., Pearson, R. E., Illig, N. A., & Morse, M. L. (1982). Medication errors in nursing homes and small hospitals. American Journal of Hospital Pharmacy, 39(6), 987-991.
10. Beers, M. H. (1997). Explicit criteria for determining inappropriate medication use by the elderly. Archives of Internal Medicine, 157, 1531-1536.
11. Beers, M. H., Avorn, J., Soumerai, S. B., Everitt, D. E., Sherman, D. S., & Salem, S. (1988). Psychoactive medication use in intermediate-care facility residents. Journal of the American Medical Association, 260, 3016-3020.
12. Beers, M. H., Fingold, S. F., Ouslander, J. G., & Al, E. (1993). Characteristics of quality prescribing by doctors practicing in nursing homes. Journal of the American Geriatrics Society, 41, 802-807.
13. Beers, M. H., Ouslander, J. G., Fingold, S. F., Morgenstern, H., Reuben, D. B., Rogers, W. et al. (1992). Inappropriate medication prescribing in skilled-nursing facilities. Annals of Internal Medicine, 117(8), 684-689.
14. Beers, M. H., Ouslander, J. G., Rollinger, J., Reuben, D. B., & Beck, J. C. (1991). Explicit criteria for determining inappropriate medication use in nursing home residents. Archives of Internal Medicine, 151, 1825-1832.
15. Bergman-Evans, B. (2004). Improving medication management for older adult clients. Retrieved October 1, 2005 at www.guidelines.gov/summary.aspx? doc_id=6222&nbr=3993&string=nursing
16. Bernabei, R., Gambassi, G., & Lapane, K. et al. (1998). Management of pain in elderly patients with cancer. SAGE study group. Systematic assessment of geriatric drug use via epidemiology. Journal of the American Medical Association, 279, 1877-1882.
17. Bernardini, B., Meinecke, C., Zaccarini, C., Bongiorni, N., Fabbrini, S., Gilardi, C., et al. (1993). Adverse clinincal events in dependent long-term nursing home residents. Journal of the American Geriatrics Society, 41(2), 105-111.
18. Boockvar, K., Fishman, E., Kyriacou, C. K., Monias, A., Gavi, S., & Cortes, T. (2004). Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Archives of Internal Medicine, 164(5), 545-550.
19. Bootman, J. L., Harrison, D. L., & Cox, E. (1997). The health care cost of drug-related morbidity and mortality in nursing facilities. Archives of Internal Medicine, 157(18), 2089-2096.
20. Briesacher, B., Limcangco, R., Simoni-Wasstila, L., Doshi, J., & Gurwitz, J. (2005). Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: A natural experiment. Journal of the American Geriatrics Society, 53, 991-996.
21. Brown, M. N., Lapane, K. L., & Luisi, A. F. (2002). The management of depression in older nursing home residents. Journal of the American Geriatrics Society, 50, 69-76.
22. Brown, N. J., Griffin, M. R., Ray, W. A. et al. (1998). A model for improving medication use in home health care patients. Journal of the American Pharmaceutical Association, 38, 696-702.
23. Cadogan, M. P., Franzi, C., Osterweil, D., & Hill, T. (1999). Barriers to effective communication in skilled nursing facilities: Differences in perception between nurses and physicians. Journal of the American Geriatric Society, 47(1), 71-75.
24. Cafiero, A. (2003). Reducing medication errors in a long-term care setting. Annals of Long-Term Care, 11(2), 29-35.
25. Cameron, K. A. (1998). Preventing medication-related problems among older Americans. Manage Care Interface, 11(10), 74-76, 78, 83-75.
26. Castle, N. G. (2003). Providing outcomes information to nursing homes: Can it improve quality of care? Gerontologist, 43, 483-492.
27. Christian, J. B., van Haaren, A., Cameron, K. A., & Lapane, K. L. (2004). Alternatives for potentially inappropriate medications in the elderly population: Treatment algorithms for use in the fleetwood phase III study. The Consultant Pharmacist, 19(11), 1011-1028.
28. Cooper, J. W. (1996). Probable adverse drug reactions in a rural geriatric nursing home population: A four-year study. Journal of the American Geriatrics Society, 44, 194-197.
29. Cooper, J. W. (1999). Adverse drug reaction-related hospitalizations of nursing facility patients: A 4-year study. Adverse Drug Reactions in Nursing Facilities, 92(5), 485-490.
30. Cooper, S., Zaske, D., Hadsall, R., Freemont, D., Suh, D. C., et al. (1994). Automated medication packaging for long-term care facilities: An evaluation. The Consultant Pharmacist, 9(1), 58-70.
31. Crawley, H. K., Eckel, F. M., & McLeod, D. C. (1971). Comparison of a traditional and unit dose drug distribution system in a nursing home. Drug Intelligence and Clinical Pharmacy, 5, 166-171.
32. Crotty, M., Halbert, J., Rowett, D., & Giles, L. (2004). An outreach geriatric medication advisory service in residential aged care: A randomised controlled trial of case conferencing. Age Ageing, 33(6), 612-617.
33. Crotty, M., Rowett, D., Spurling, L., Giles, L. C., & Phillips, P. A. (2004). Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. American Journal of Geriatric Pharmacotherapy, 2(4), 257-264.
34. Dhalla, I. A., Anderson, G. M., Mamdani, M. M., Bronskill, S. E., Skyora, K., & Rochon, P. A. (2002). Inappropriate prescribing before and after nursing home admission. Journal of the American Geriatrics Society, 50(6), 995-1000.
35. Fialova, D., Topinkova, E., Gambassi, G., Finne-Soveri, H., Jonsson, P. V., Carpenter, I., Schroll, M., Onder, G., Sorbye, A. W., Wagner, C., Reissigova, J., & Nernabei, R., for the AdHoc Project Research Group. (2005). Potentially inappropriate medication use among elderly home care patients in Europe. Journal of the American Medical Association, 293, 1348-1358.
36. Feinberg, J. L., Cameron, K. A., Lapane, K. L., & Allsworth, J. E. The use of GRAM(TM) software to improve patient safety in nursing facilities.
37. Fick, D. M., Cooper, J. W., Wade, W. E., Waller, J. L., Maclean, J. R., & Beers, M. H. (2003). Updating the beers criteria for potentially inappropriate medication use in older adults. Archives of Internal Medicine, 163, 2716-2725.
38. Field, T. S., Gurwitz, J. H., Avorn, J., McCormick, D., Jain, S., Eckler, M. et al. (2001). Risk Factors for adverse drug events among nursing home residents. Archives of Internal Medicine, 161(13), 1629-1634.
39. Gambassi, G., Forman, D. E., Lapane, K. L., Mor, V., Sgadari, A., Lipsitz, L. A., & Bernabei, R. on behalf of The SAGE Study Group. (2000). Management of heart failure among very old persons living in long term care: Has the voice of trials spread? American Heart Journal, 139(1), 85-89.
40. Garrard, J., Chen, V., & Dowd, B. (1995). The impact of the 1987 federal regulations on the use of psychotropic drugs in Minnesota nursing homes. American Journal of Public Health, 85(6), 771-776.
41. General Accounting Office (GAO). (2000). Adverse drug events: The magnitude of health risk is uncertain because of limited incidence data. Washington, DC: General Accounting Office. Available at http://www.gao.gov/ new.items/he00021.pdf
42. Gerety, M. B., Cornell, J. E., Plichta, D. T., & Eimer, M. (1993). Adverse events related to drugs and drug withdrawal in nursing home residents. Journal of the American Geriatrics Society, 41(12), 1326-1332.
43. Gupta, S., Rappaport, H. M., & Bennett, L. T. (1996a). Inappropriate drug prescribing and related outcomes for elderly medicaid beneficiaries residing in nursing homes. Clinical Therapeutics, 18(1), 183-196.
44. Gupta, S., Rappaport, H. M., & Bennett, L. T. (1996b). Polypharmacy among nursing homes geriatric medicaid recipients. The Annals of Pharmacotherapy, 30, 946-949.
45. Gurvich, T. & Cunningham, J. A. (2000). Appropriate use of psychotropic drugs in nursing homes. American Family Physician, 61, 1437-1446
46. Gurwitz, J. H., Field, T. S., Avorn, J., McCormick, D., Jain, S., Eckler, M. et al. (2000). Incidence and preventability of adverse drug events in nursing homes. American Journal of Medicine, 109(2), 87-94.
47. Gurwitz, J. H., Field, T. S., Judge, J., Rochon, P., Harrold, L. R., Cadoret, C. et al. (2005). The incidence of adverse drug events in two large academic long-term care facilities. The American Journal of Medicine, 118(3), 251-258.
48. 2 receptor antagonists in the long term setting. Journal of the American Geriatrics Society, 40, 359-364.
49. Gurwitz, J. H., Sanchez-Cross, M. T., Eckler, M. A., & Matulis, J. (1994). The epidemiology of adverse and unexpected events in the long term care setting. Journal of the American Geriatrics Society, 42(1), 33-38.
50. Gurwitz, J. H., Soumerai, S. B., & Avorn, J. (1990). Improving medication prescribing and utilization in the nursing home. Journal of the American Geriatrics Society, 38(5), 542-552.
51. Handler, S. M., Nace, D. A., Studenski, S. A., & Fridsma, D. B. (2004). Medication error reporting in long term care. American Journal of Geriatric Pharmacotherapy, 2, 190-196.
52. Hanlon, J. T., Lindblad, C. I., Hajjar, E. R., & McCarthy, T. C. (2003). Update on drug-related problems in the elderly. The American Journal of Geriatric Pharmacotherapy, 1(1), 38-43.
53. Harjivan, C. & Lyles, A. (2002). Improved medication use in long-term care: Building on the consultant pharmacist's drug regimen review. American Journal of Managed Care, 8(4), 318-326.
54. Harrison, D., Bootman, J., & Cox, E. (1998). Cost-effectiveness of consultant pharmacists in managing drug-relatedmorbidity andmortality at nursing facilities. American Journal of Health-System Pharmacy, 55(15), 1588-1594.
55. Horgas, A. L. (1992). Prescription drug use and drug-drug interactions in nursing homes: Prevalence, predictors, and health outcomes Dissertation Abstracts Online.
56. Howland, C. W. (1993). Time series evaluation of nursing home reform (1987): Psychotropic medications prescribed in a state center for adults with severe/profound developmental disabilities. Dissertation Abstracts Online.
57. Hughes, C. M., Lapane, K. L., & Mor, V. (2000). Influence of facility characteristics on use of antispychotic medication in nursing homes. Medical Care, 38(12), 1164-1173.
58. Hughes, C. M., Lapane, K. L., Mor, V., Ikegami, N., Jonsson, P. V., Ljunggren, G., et al. (2000). The impact of legislation on psychotropic drug use in nursing homes: A cross-national perspective. Journal of the American Geriatrics Society, 48(8), 931-937.
59. Hutt, E., Pepper, G. A., Vojir, C., Fink, R., & Jones, K. R. (2006). Assessing appropriateness of pain medication prescribing practices in nursing homes. Journal of the American Geriatrics Society, 54(2), 231-239.
60. Jensen, L. A. & Allen, M. N. (1996). Metasynthesis of qualitative findings. Qualitative Health Research, 6(4), 553-560.
61. Jones, K. R., Fink, R., Pepper, G. A., Hutt, E., & Mellis, B. K. (2004). Improving nursing home staff knowledge and attitudes about pain. The Gerontologist, 44, 469-478.
62. Jones, K. R., Fink, R. M., Clark, L., Hutt, E., Vojir, C. P., & Mellis, B. K. (2005). Nursing home resident barriers to effective pain management: Why nursing home residents may not seek pain medication. Journal of the American Medical Directors Association, 6(1), 10-17.
63. Jones-Schenk, J. (2004). Summary of findings: Survey of state regulators certified nurses aides. Stanford, CT: Capstar. Division of the Chauncy Group.
64. Kane, R. L., Williams, C. C., Williams, T. F., & Kane, R. A. (1993). Restraining restraints: Changes in a standard of care. Annual Review of Public Health, 14, 545-584.
65. Kidder, S. W. (1999). Regulation of inappropriate psychopharmacologic medication use in U.S. nursing homes from 1954 to 1997: Part II. Annals of Long Term Care, 7, 56-62.
66. Lane, C. J., Bronskill, S. E., Skyora, K., Dhalla, I. A., Anderson, G. M., Mamdani, M. M. et al. (2004). Potentially inappropriate prescribing in Ontario Community- Dwelling Older Adults and Nursing Home Residents. Journal of the American Geriatrics Society, 52(6), 861-866.
67. Lantz, M. S., Giambanco, V., & Buchalter, E. N. (1996). A ten-year review of the effect of OBRA-87 on psychotropic prescribing practices in an academic nursing home. Psychiatric Services, 47(9), 951-955.
68. Lapane, K. L. & Hughes, C. M. (2004a). Identifying nursing home residents at high risk for preventable adverse drug events: Modifying a tool for use in the Fleetwood Phase III study.
69. Lapane, K. L. & Hughes, C. M. (2004b). Which organizational characteristics are associated with increased management of depression using antidepressants in US nursing homes? Medical Care, 42(10), 992-1000.
70. Lau, D. T., Kasper, J. D., Potter, D. E. B., & Lyles, A. (2004). Potentially inappropriate medication prescriptions among elderly nursing home residents: Their scope and associated resident and facility characteristics. Health Services Research, 39(5), 1257-1276.
71. Lau, D. T., Kasper, J. D., Potter, D. E. B., Lyles, A., & Bennett, R. G. (2005). Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Archives of Internal Medicine, 165(1), 68-74.
72. Lepinski, P. W., Thielke, T. S., Collins, D. M., & Hanson, A. (1986). Cost comparison of unit does and traditional drug distribution in a long-term care facility. American Journal of Hospital Pharmacy, 43(11), 2771-2779.
73. Llorente, M. D., Olsen, E. J., Leyva, O., Silverman, M. A., Lewis, J. E., & Rivero, J. (1998). Use of antipsychotic drugs in nursing homes: Current compliance with OBRA regulations. Journal of the American Geriatrics Society, 46(2), 198-201.
74. McCormick, D., Gurwitz, J. H., Goldberg, R. J., Becker, R., Tate, J. P., Elwell, A., & Radford, A. J. (2001). Prevalence and quality of warfarin use for patients with atrial fibrillation in the long term care setting. Archives of Internal Medicine, 161, 2458-2463.
75. McGhan, W. F., Einarson, T. R., Sabers, D. L. et al. (1987). A meta-analysis of the impact of pharmacist drug regimen in long term care facilities. Journal of Geriatric Drug Therapy, 1, 23-34.
76. McLeod, P. J., Huang, A. R., Tamblyn, R. M., & Gayton, D. C. (1997). Defining inappropriate practices for prescribing for elderly people: A national consensus panel. Canadian Medical Association Journal, 156, 389-391.
77. McMillan, I. (2004). One home in eight fails to meet medication standards. Learning Disability Practice, 7(3), 4.
78. Meredith, S., Feldman, P. H., Frey, D., Hall, K., Arnold, K., Brown, N. J. et al. (2001). Possible medication errors in home healthcare patients. Journal of the American Geriatrics Society, 49, 719-724.
79. Neriuoka, B. (1986). Improving medication delivery in an extended care unit. Dimensions in Health Service, 63(4), 26.
80. Novek, J., Bettess, S., Burke, K., & Johnston, P. (2000). Nurses' perceptions of the reliability of an automated medication dispensing system. Journal of Nurse Care Quality, 14(2), 1-13.
81. Nygaard, H. A., Naik, M., Ruths, S., & Straand, J. (2003). Nursing home residents and their drug use: A comparison between mentally intact and mentally impaired residents. European Journal of Clinical Pharmacology, 59, 463-469.
82. Office of the Inspector General (OIG). (2001). Psychotropic drug use in nursing homes. Washington, DC: Office of Health and Human Services.
83. Patterson, E. S., Rogers, M. L., & Render, M. L. (2004). Fifteen best practice recommendations for bar-code medication administration in the Veterans Health Administration. Joint Commission Journal of Quality and Safety, 30(7), 355-365.
84. Pelletier, P. L. (1999). Errors and omissions. Study looks to survey for insights on drug errors. Contemporary Long term Care, 22(10), 67.
85. Perri, M., III, Menon, A. M., Deshpande, A. D., Shinde, S. B., Jiang, R., Cooper, J. W. et al. (2005). Adverse outcomes associated with inappropriate drug use in nursing homes. Annals of Pharmacotherapy, 39(3), 405-411.
86. Phillips, C. D., Spry, K. M., Sloane, P. D., & Hawes, C. (2000). Use of physical restraints and psychotropic medication in alzheimer special care units in nursing homes. American Journal of Public Health, 90(1), 92-96.
87. Piercoro, L. T., Browning, S. R., Prince, T. S., Rantz, T. T., & Scutchfield, F. D. (2000). A database analysis of potentially inappropriate drug use in an elderly medicaid population. Pharmacotherapy, 20(2), 221-228.
88. Randolph, J., Magro, J., Stalmach, D., Cermak, B., & Wilson, B. (1999). A study of the accuracy of telephone orders in nursing homes in southern California. Annals of Long-Term Care, 7(9), 334-338.
89. Ray, W. A., Blazer, D. G., Schaffner, W. et al. (1987). Reducing antipsychotic drug prescribing for nursing home patients: A controlled trial of the effect of an educational visit. American Journal of Public Health, 77, 1448-1450.
90. Rivers, P. H. & Poston, J. W. (1985). Evaluation of a controlled medication system. Pharmaceutical Journal, 85, 787-789.
91. Rollason, V. & Vogt, N. (2003). Reduction of polypharmacy in the elderly: A systematic review of the role of the pharmacist. Drugs and Aging, 20 (11), 817-832.
92. Roberts, M. S., Stokes, J. A., King, M. A., Lynne, T. A., Purdie, D. M., Glasziou, P. P. et al. (2001). Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Journal of Clinical Pharmacology, 51(3), 257-265.
93. Rochon, P. A., Field, T. S., Bates, D. W., Lee, M., Gavendo, L., Erramuspe-Mainard, J. et al. (2005). Computerized physician order entry with clinical decision support in the long-term care setting: Insights from the Baycrest center for geriatric care. Journal of the American Geriatrics Society, 53(10), 1780-1789.
94. Ruffin, D. M. & Hodge, F. J. (1995). Pharmacists' impact on medication administration errors in long-term care facilities. The Consultant Pharmacist, 10(10), 1025-1032.
95. Ruths, S., Straand, J., & Nygaard, H. A. (2003). Multidisciplinary medication review in nursing home residents: What are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. Quality and Safety in Health Care, 12(3), 176-180.
96. Schmidt, I. K. & Svardtad, B. L. (2002). Nurse-physician communication and quality of drug use in Swedish nursing homes. Social Science Medicine, 54, 1767-1777.
97. Scott-Cawiezell, J., Pepper, G. A., Madsen, R., Petroski, G., Vogelsmeier, A., & Zellmer, D. (2005). Level of nursing residential and interruptions: What is the impact on nursing home medication administration accuracy. Unpublished manuscript in preparation for project funded by AHRQ 5UC1 HS 14281-02.
98. Semla, T. P., Palla, K., Poddig, B., & Brauner, D. J. (1994). Effect of the omnibus reconciliation act 1987 on antipsychotic prescribing in nursing home residents. Journal of the American Geriatrics Society, 42, 648-652.
99. Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). Experimental and quasi-experimental designs for generalized causal inference. Boston, MA: Houghton Mifflin Company.
100. Siple, J. F. & Joseph, C. L. (1992). Medication discrepancies on admission to a nursing home. American Journal of Hospital Pharmacy, 49, 397-400.
101. Sloane, P. D., Zimmerman, S., Brown, L. C., Ives, T. J., & Walsh, J. F. (2002). Inappropriate medication prescribing in residential care/assisted living facilities. Journal of the American Geriatrics Society, 50, 1001-1011.
102. Sloane, E. J. & Glazer, W. (1995). Use of OBRA-87 guidelines for prescribing neuroleptics in a VA nursing home. Psychiatric Services, 46, 119-121.
103. Soumerai, S. & Avorn, J. (1987). Predictors of physician prescribing change in an educational experiemnt to improve medications use. Medical Care, 25, 210-222.
104. Soumerai, S. B., Ross-Degnan, D., Avorn, J., McLaughlin, T., & Choodnovskiy I. (1991). Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. New England Journal of Medicine, 325(15), 1072-1077.
105. Spreat, S. & Conroy, J. (1998). Use of psychotropic medications for persons with mental retardation who live in Oklahoma nursing homes. Psychiatric Services, 49, 510-512.
106. Stuart, B., Kamal-Bahl, S., Briesacher, B., Lee, E., Doshi, J., Zuckerman, I. H., Verovsky, I., Beers, M. H., Erwin, G., & Friedley, N. (1999). Trends in the prescription of inappropriate drugs for the elderly between 1995 and 1999. American Journal of Geriatric Pharmacotherapy, 1(2), 61-74.
107. Svarstad, B. I. & Mount, J. K. (1991). Nursing home resources and tranquilizer use among institutionalized elderly. Journal of the American Geriatrics Society, 38, 769-775.
108. Svarstad, B. L. & Mount, J. K. (2001). Chronic benzidiazepine use in nursing homes: Effects of federal guidelines, resident mix, and nurse staffing. Journal of the American Geriatric Society. 49, 1673-1678.
109. Svarstad, B. L., Mount, J. K., & Bigelow, W. (2001). Variations in the treatment culture of nursing homes and responses to regulations to reduce drug use. Pyschiatric Services, 52(5), 666-672.
110. Swagerty, D. & Brickley, R. (2004). Joint Position Statement on the Beers List of Potentially Inappropriate Medications in Older Adults. Retrieved on November 1, 2005 from http://www.ascp.com/public/ga/2005/docs/ ASCPAMDABeers.pdf
111. Taylor, L. F., Strasser, D. C., Miller, S. W., Hennessy, C. H., & Archea, C. (2003). Psychotropic drug use in a nursing home: A 6-year retrospective. The Journal of Applied Gerontology, 22(4), 474-489.
112. Thornely, S. M., Carmichael, J. M., & Bryg, R. J. (1992). Effect of clinincal pharmacy input on physician prescribing habits in the nursing home care unit. Hospital Pharmacy, 27(7), 616-617, 621.
113. van Dijk, K. N., Pont, L. G., de Vries, C. S., Franken, M., Brouwers, J. R., & de Jong-van den Berg, L. T. (2003). Prescribing indicators for evaluating drug use in nursing homes. Annals of Pharmacotherapy, 37(7), 1136-1141.
114. VanHaaren, A. M., Lapnae, K. L., & Hughes, C. M. (2001). Effect of triplicate prescription policy on benzodiazepine administration in nursing home residents. Pharmacotherapy, 21, 1159-1166.
115. Vogelsmeier, A., Scott-Cawiezell, J., & Zellmer, D. (2007). Barriers to safe medication administration in the nursing home-exploring staff perceptions and concerns about the medication use process. Journal of Gerontological Nursing, 33(4), 5-12.
116. Williams, B., Thompson, J., & Brummel-Smith, K. (1993). Improving medication use in the nursing home. In L. Z. Rubenstein & D. Wieland (Eds). Improving Care in the Nursing Home: Comprehensive Reviews of Clinical Research. (pp. 33-64). Newbury Park, CA: Sage Publications.
117. Won, A., Lapane, K., Gambassi, G. et al. (1999). Correlates and management of non-malignant pain in the nursing home. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology. Journal of the American Geriatrics Society, 47, 936-942.
118. Won, A. B., Lapane, K. L., & Vallow, S. et al. (2004). Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. Journal of the American Geriatrics Society, 52, 867-874.
119. Wright, D. (2002). Medication administration in nursing homes. Nursing Standard, 16(42), 33-38.
120. Wrong patient gets insulin: $6.5 Million settlement: Nursing personnel had criminal background. (1999). Healthcare Risk Management, 21(11), 3-4.
121. Young, H. M., Sikma, S. K., Bothell, S. L., Christlieb, C. & Trippett, L. S. J. (2005). Medication observations in assisted living: Methodological issues. Paper presented at Gerontological Association of America meeting in Orlando FL, November 19.
122. Zuckerman, I. H. (2005) Inappropriate medication use and transition to nursing home among community-dwelling elderly. Dissertation Abstracts Online.
123. Zullich, S. G., Grasela, T. H., Fiedler-Kelly, J. B., & Gengo, F. M. (1993). Changes in prescribing patters in long-term care facilities and impact on incidence of adverse events. National Institute of Drug Abuse Research Monograph, 131, 294-308.