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Medication errors plague nursing home residents

Each month, nearly one out of every 10 nursing home residents suffers a medication-related injury, according to a study by Massachusetts researchers that suggests the problem is far more widespread than previously estimated.

The study found that 73 percent of the most severe injuries -- including internal bleeding and death -- were preventable, along with many of the others. The most common problems were confusion, oversedation, hallucinations, or bleeding due to prescribing errors or failure to carefully monitor patients for side effects. The researchers found that warfarin, a blood thinner, and antipsychotic drugs caused the most problems.

"This seems to be a major safety issue for some of our most vulnerable patients," said Dr. Jerry Gurwitz, the lead author of the study released today, and a professor at the University of Massachusetts Medical School.

While the medical profession has increasingly focused on reducing medical errors in hospitals, Gurwitz said nursing homes are "at least 10 years behind in making the changes necessary" to address the problem. Many nursing homes cannot afford the expensive computerized medication dispensing and monitoring systems that hospitals are purchasing. And few nursing homes have found ways to minimize the problems resulting from having many different doctors treating patients -- often by telephone, Gurwitz said.

Massachusetts, however, is about to launch a program to reduce medication errors in nursing homes. With a $197,000 state grant, the Massachusetts Coalition for the Prevention of Medical Errors has hired a consultant to work with 25 nursing homes, yet to be selected.

The consultant will also develop specific plans -- such as ways to doublecheck a patient's identity and prescribing orders -- that other nursing homes can follow.

"We want to make sure these residential patients -- our mothers, fathers, and relatives -- are as safe as they can be and don't experience any unnecessary pain or unnecessary suffering," said Nancy Ridley, associate commissioner of public health and director of the Betsy Lehman Center for Patient Safety and Medical Error Reduction.

The state requires nursing homes to report medical errors that seriously harm patients. Last year, 48 errors were reported at the roughly 480 homes in Massachusetts, down from 51 in 2003. Paul Dreyer, the state official who oversees nursing home care, said there may be under-reporting, but "I hope our numbers are smaller" than the research suggests.

In one case investigated by the state late last year, a medication error left a resident struggling to breathe. The resident missed 22 doses of a diuretic over 11 days because a doctor's orders to increase the dose were not entered into the patient's medical record, Dreyer said. The water build-up put the resident in respiratory distress.

In Gurwitz's study, published in the American Journal of Medicine, he and his colleagues scrutinized drug-related problems at two large nursing homes affiliated with major medical centers in Connecticut and Ontario. They found 815 injuries, including four deaths, over nine months in 2000 and 2001 -- a rate of roughly 10 injuries a month for every 100 nursing home residents. They determined that 42 percent of the problems were preventable.

"You would hope for an error rate that is more than one in a million rather than one in 10," said Dr. David Blumenthal, director of the Institute for Health Policy at Massachusetts General Hospital and Partners Healthcare, who was not involved in the study. "It shows how far we are from realizing the standards of safety and reduction in errors that are prevalent in other parts of the economy, such as the airline industry."

The study was an intensive follow-up to research four years ago in 18 smaller Massachusetts nursing homes that found a significant, but lower, rate of complications. Gurwitz said little, if anything, has changed in nursing homes' handling of medicines since the data was collected.

"These rates are five times the numbers we previously identified," Gurwitz said. "If this is going on in these types of top-flight facilities that . . . have more resources, more staff and greater involvement of physicians, it's without question happening more in community-based facilities. These numbers should be considered conservative."

Extrapolated to the nation's 1.6 million nursing home residents, the new research suggests there are 1.9 million drug-related problems each year, including more than 86,000 fatal or life-threatening problems. The previous estimate was 350,000 problems, including 20,000 that were fatal or life-threatening.

Sandra Akers, a member of a new state expert panel overseeing reduction of medication errors, and a nurse executive at the Chelsea Soldiers' Home, an 88-bed nursing home, said she is worried the study will scare the public. Akers, who is also chief nursing officer at Tewksbury Hospital, said nursing homes are lagging hospitals in addressing medical errors because they are financially strapped.

Gurwitz said relatives of nursing home patients need to be alert to possible medication errors.

"They're often the most capable of recognizing that there has been a change in the status of their relative," he said. "The best way to do that is to know what's going on, ask a lot of questions, and understand what medications their relatives are on, why they're on them, and what the side effects are."

Alice Dembner can be reached at dembner@globe.com.

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