Does Rx spell trouble in SNFs?

Can these errors be tallied and attributed accurately?

HOW MANY PREVENTABLE DRUG ERRORS take place in SNFs every year, and who's to blame?

An estimated 150,000 United States nursing home patients suffer adverse drug reactions each year--from dizziness to dangerous falls to potentially fatal liver damage--because the staff makes preventable errors in prescribing and managing medications, according to a study conducted by researchers from the University of Massachusetts Medical School and Brigham and Women's Hospital. The study found 546 medication-related injuries at 18 Massachusetts nursing homes over a one-year span, including one death and 31 injuries that were life-threatening.

The study then reportedly goes on to presume that this translates to an estimated 350,000 adverse drug events yearly in nursing homes, 20,000 of which are fatal or life-threatening, according to Jerry Gurwitz, MD, a gerontologist at UMass, one of the researchers in the study. About half of those events could have been prevented, he says.

While the 1999 Institute of Medicine (IOM) report concludes that as many as 98,000 Americans die every year from preventable medical errors, it is being criticized as erroneous by some experts, according to a recent article in The Washington Post. Apparently there is difficulty in accurately tallying medical errors, and the available data do not support IOM's claim of large numbers of deaths caused by adverse events, preventable or otherwise, the Post reports.

AAHSA had this to say to Contemporary Long Term Care: "Everyone should be concerned about the possibility of medication errors. However, the data reported in the study are out-of-date, since a new drug protocol was put into practice July 1, 1999, after the data for this study were collected. [See "Dos and doses: Techniques to prevent medication errors and inappropriate use," June 2000 CLTC, page 40.] One significant aspect of the new protocol was the development and mandated use of the Beers list of drugs that helped to minimize adverse drug interactions in the elderly."

"This has always been a 'forgotten' population,' says Gurwitz, executive director at the Meyers Primary Care Institute, an initiative of Fallon Health Care systems and UMass Medical School.

Scott Plumb, senior vice president of the Massachusetts Extended Care Federation, which represents nursing homes, says the report was not entirely surprising.

"We're taking care of far more seriously ill patients than in the past, with frail patients on more and more medications," he says. "Secondly, we're in the middle of the worst staffing crisis we've had" since Medicare was established in the 1960s. One in 10 nursing positions is unfilled, and there is a high turnover rate of less-skilled staff.

The study found one death during the year-long observation, a patient who died from liver damage. Other patients were oversedated, had severe allergic reactions, developed bleeding that sometimes required transfusions, fell, broke bones, got infections, suffered weight loss, or experienced other ill effects, the report says.

In addition to the errors, the researchers note 188 errors that could have resulted in adverse effects but did not.

Nursing home patients may be more vulnerable to drug reactions, Gurwitz says, because doctors do not spend a lot of time there and do a lot of "telephone medicine" where patient records are not always at hand.

Charles H. Roadman II, MD, president and CEO of the American Health Care Association, says that Gurwitz's study brings into relief a genuine concern, but falls short by failing to identify the lack of an integrated health system as part of the cause. "Dr. Gurwitz's study on drug errors in nursing facilities raises valid questions about errors in nursing facilities relating to improperly prescribed medication, yet the fact remains that this is a national problem affecting every segment of the health care community, and better coordination between all providers of health care is a necessity. Where human lives are concerned, there is no room for error, and we recognize the need for improvements. However, for our nation to solve this problem, we need a more integrated health care system that addresses the continuum of care and the patient needs," he says.

"Widely publicized stories in recent months that focus on prescription drug errors, and the related problem with adverse drug interactions, have made the entire health care community more cognizant of the need to improve prescription procedures, and to better research patients' drug intake to avoid interaction complications," he continues.

"One important element of the broader picture not covered in the study concerns the potential for inadequate transfer of medication records as patients are admitted to skilled nursing facilities. Also, the Health Care Financing Administration has not put in place a new medical reimbursement rate that would help pay for specialty packaging and other measures that help alleviate errors," Roadman says.

"Dr. Gurwitz also fails to mention that not only have severe and damaging Medicare and Medicaid funding shortfalls put enormous strain on skilled nursing facilities, but that facilities are facing the worst nurse staffing shortage in recent memory. While the nursing shortage is largely a function of a booming, full-employment economy, state and federal governments must more adequately reimburse nursing facilities relative to the actual cost of serving patients," he says. Roadman concludes that while there is certainly room for improvement in coordinating patient prescription information among members in the provider chain, state and federal funding shortfalls remain the most vexing underlying systemic problems facing the long-term care community.

"It's clearly time for skilled nursing care to become the financial priority it needs and deserves to be," he says.