Predictors of medication errors among elderly hospitalized patients

American Journal of Medical Quality

Volumn 23, Issue 2, 2008, Pages 115-127

  Picone, Debra Matsen ^a   Titler, Marita G ^a   Dochterman, Joanne ^b   Shever, Leah ^b   Kim, Taikyoung ^b   Abramowitz, Paul ^a   Kanak, Mary ^b,c   Qin, Rui ^b,d  

^a UNIVERSITY OF IOWA HOSPITALS AND CLINICS   (United States)

^b UNIVERSITY OF IOWA COLLEGE OF NURSING   (United States)

^c Mercy Hospital   (United States)

^d MAYO CLINIC   (United States)

Author keywords

Adverse drug events; Medication errors; Retrospective study; Safety

Indexed keywords

AGE; AGED; ARTICLE; CLASSIFICATION; COMORBIDITY; DRUG UTILIZATION; HEALTH CARE QUALITY; HOSPITAL MANAGEMENT; HOSPITALIZATION; HUMAN; MEDICATION ERROR; NURSING STAFF; ORGANIZATION AND MANAGEMENT; PERSONNEL MANAGEMENT; POLYPHARMACY; RETROSPECTIVE STUDY; SEX DIFFERENCE; SOCIOECONOMICS; STATISTICS; TEACHING HOSPITAL;

AGE FACTORS; AGED; COMORBIDITY; DRUG UTILIZATION; HOSPITAL ADMINISTRATION; HOSPITALS, TEACHING; HUMANS; MEDICATION ERRORS; NURSING STAFF, HOSPITAL; PERSONNEL STAFFING AND SCHEDULING; POLYPHARMACY; QUALITY ASSURANCE, HEALTH CARE; RETROSPECTIVE STUDIES; SEVERITY OF ILLNESS INDEX; SEX FACTORS; SOCIOECONOMIC FACTORS;

EID: 41149096659     PISSN: 10628606     EISSN: 1555824X     Source Type: Journal    
DOI: 10.1177/1062860607313143     Document Type: Article

References (53)

1. Hughes RG, Ortiz E. Medication errors: why they happen, and how they can be prevented. Am J Nurs. 2005 ; 105 (3 suppl.). 14-24.
2. Bates DW, Cullen DJ, Laird N., et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995 ; 274: 29-34.
3. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997 ; 277: 301-306.
4. Douglas J., Larrabee S. Bring barcoding to the bedside: Patient Safety Series, Part 1 of 2: implement information technology to track and reduce medication errors. Nurs Manage. 2003 ; 34: 36-40.
5. Barker KN, Flynn EA, Pepper GA Observation method of detecting medication errors. Am J Health Syst Pharm. 2002 ; 59: 2314-2316.
6. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995 ; 274: 35-43.
7. Lambert BL, Lin SJ, Chang KY, Gandhi SK Similarity as a risk factor in drug-name confusion errors: the look-alike (orthographic) and sound-alike (phonetic) model. Med Care. 1999 ; 37: 1214-1225.
8. Institute for Safe Medication Practices. Survey on high-alert medications. Differences between nursing and pharmacy perspectives revealed. ISMP Medication Safety Alert! Acute Care edition. 2003 ; October:8.
9. Schafer SL Prescribing for seniors: it's a balancing act. J Am Acad Nurs Pract. 2001 ; 13: 108-112.
10. Grymonpre RE, Mitenko PA, Sitar DS, Aoki FY, Montgomery PR Drug-associated hospital admissions in older medical patients. J Am Geriatr Soc. 1988 ; 36: 1092-1098.
11. Kaufman DW, Kelly JP, Rosenbery L., Anderson TE, Mitchell AA Recent patterns of medication use in the ambulatory adult population in the United States: the Slone Survey. JAMA. 2002 ; 287: 337-344.
12. Baum C., Kennedy DL, Forbes MB, Jones JK Drug use in the United States in 1981. JAMA. 1984 ; 251: 1293-1297.
13. Chrischilles EA, Foley DJ, Wallice RB, et al. Use of medications by persons 65 and over: data from the established populations for epidemiologic studies of the elderly. J Gerontol. 1992 ; 47: M137 - M144.
14. McDonough RP, Cooper JW Drug-related problems in older adults. J Am Pharm Assoc. 2002 ; 42 (5 suppl. 1). S32 - S33.
15. Lindley CM, Tully MP, Paramsothy V., Tallis RC Inappropriate medication is a major cause of adverse reactions in elderly patients. Age Ageing. 1992 ; 21: 294-300.
16. Cameron KA Preventing medication-related problems among older Americans. Manag Care Interface. 1998 ; 11: 74-85.
17. Stewart RB, Caranasos GJ Medication compliance in the elderly. Med Clin North Am. 1989 ; 73: 1551-1563.
18. Liu GG, Christensen DB The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc. 2002 ; 42: 847-857.
19. Titler MG Nursing interventions and outcomes in 3 older populations. Grant # 5 R01 NR05331-02. National Institute of Nursing Research and The Agency for Healthcare Research and Quality, 07/01/2001-03/31/2005; 2000.
20. Dochterman JM, Bulechek GM, eds. Nursing Interventions Classification (NIC). 4 th ed. St. Louis, MO: Mosby ; 2004.
21. Gyldevand TA Falls: The Construction and Validation of the Risk Assessment for Falls Scale II (RAFS II) [thesis]. Iowa City, IA: University of Iowa ; 1984.
22. Titler M., Dochterman JM, Reed D. Guideline for Conducting Effectiveness Research in Nursing and Other Healthcare Services. Iowa City, IA: Center for Nursing Classification & Clinical Effectiveness; 2004.
23. Titler MG, Dochterman JM, Kim T., et al. Components of cost of care for older adults hospitalized for hip fracture and related procedures. Nurs Outlook. 2007 ; 55: 5-14.
24. Healthcare Cost and Utilization Project (HCUP). Clinical Classification Software (CCS) for ICD-9-CM. Rockville, MD: Agency for Healthcare Research and Quality ; 2006. http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Accessed January 2006.
25. Elixhauser A., Steiner C., Harris DR, Coffey RM Comorbidity measures for use with administrative data. Med Care. 1998 ; 36: 8-27.
26. Budreau G., Balakrishnan R., Titler M., Hafner MJ Caregiverpatient ratio: capturing census and staffing variability. Nurs Econ. 1999 ; 17: 317-324.
27. McEvoy GK AHFS Drug Information. Bethesda, MD: American Society of Health-Systems Pharmacists ; 2000.
28. Diggle PJ, Heagerty P., Liang K. -Y, Zeger SL Analysis of Longitudinal Data. 2 nd ed. Oxford, UK: Oxford University Press ; 2002.
29. Sas/Stat User's Guide [computer program]. Version 9. Cary, NC: SAS Institute ; 2004.
30. Cox DR, Hinkley DV Theoretical Statistics. New York, NY: Wiley ; 1974.
31. Institute for Safe Medication Practices. ISMP's List of High-Alert Medication. Huntingdon Valley, PA: Institute for Safe Medication Practices ; 2005.
32. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory care setting. JAMA. 2003 ; 289: 1107-1116.
33. Bates DW, Leap LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998 ; 280: 1311-1316.
34. Hicks R. The MEDMARX Database. Am J Nurs. 2005 ; 105 (3 suppl.). S45 - S47.
35. Fields TS, Gurwitz JH, Avorn J., et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med. 2001 ; 161: 1629-1634.
36. Rochon PA, Gurwitz JH Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997 ; 315: 1096-1099.
37. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med. 1993 ; 8: 289-294.
38. Pronovost P., Weast B., Schwarz M., et al. Medication reconciliation: a practice tool to reduce the risk of medication errors. J Crit Care. 2003 ; 18: 201-205.
39. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF The working hours of hospital staff nurses and patient safety. Health Aff. 2004 ; 23: 202-212.
40. Rich LV How we think about medication errors: a model and charge for nurses. Am J Nurs. 2005 ; 105 (3 suppl.). S10 - S11.
41. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL Medication errors observed in 36 health care facilities. Arch Intern Med. 2002 ; 162: 1897-1903.
42. Bates DW, Evans RS, Murff H., Stetson PD, Pizziferri L., Hripcsak G. Detecting adverse events using information technology. J Am Med Inform Assoc. 2003 ; 10: 115-128.
43. Agency for Healthcare Research and Quality. Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. Research in Action, Issue 1. AHRQ Publication Number 01-0020. Rockville, MD: Agency for Healthcare Research and Quality ; 2001. http://www.ahrq.gov/qual/aderia/aderia.htm. Accessed January 2006.
44. Bell DS, Cretin S., Marken RS, Landman AB A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc. 2004 ; 11: 60-70.
45. Bizovi KE, Beckley BE, McDade MC, et al. The effect of computer-assisted prescription writing on emergency department prescription errors. Acad Emerg Med. 2002 ; 9: 1168-1175.
46. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy. 2002 ; 22: 134-147.
47. Chrischilles EA, Fulda TR, Byrns PJ, Winckler SC, Rupp MT, Chui MA The role of pharmacy computer systems in preventing medication errors. J Am Pharm Assoc. 2002 ; 42: 439-448.
48. Glassman PA, Simon B., Belperio P., Lanto A. Improving recognition of drug interactions: benefits and barriers to using automated drug alerts. Med Care. 2002 ; 40: 1161-1171.
49. Institute for Safe Medication Practices. A Call to Action: Eliminate Handwritten Prescriptions within 3 Years: Electronic Prescribing Can Reduce Medication Errors. Huntingdon Valley, PA: Institute for Safe Medication Practices ; 2000.
50. Raschke R., Gollihare B., Wunderlich T., et al. A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital. JAMA. 1998 ; 280: 1317-1320.
51. Cho S., Ketefian S., Barkauskas VH, Smith DG The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003 ; 52: 71-79.
52. Gurwitz JH Polypharmacy: a new paradigm for quality drug therapy in the elderly ? Arch Intern Med. 2004 ; 165: 1957-1959.
53. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002 ; 59: 436-446.