Abstract
Objective
This study examined the association between the administration of drugs to the wrong
nursing home residents with a need for hospital treatment or as an indicator of mortality.
Design
A retrospective observational study of medical records from February 1, 2016, to January
31, 2017.
Setting
Calls made to the Quebec Poison Center.
Participants
Nursing home residents aged ≥65 years.
Intervention(s)
Medication administered to the wrong resident.
Main Outcome Measure(s)
Death, hospital referral and treatment, number of drugs or type of drug classes.
Results
Of the 6282 calls received by the Quebec Poison Center concerning medication errors,
494 cases were included in the retrospective study. Half of the patients (51%) received
at least 5 different drugs that were not prescribed for them. Most patients (82%)
were asymptomatic at the time of the call to the poison center; however, a third (34%)
of the exposures were considered potentially toxic and were treated at the hospital.
The most prominent drug classes involved include antihypertensives, antiarrhythmics,
and antipsychotics. In particular, almost a quarter (23%) of cases of clozapine maladministration
resulted in moderate or severe effects. No deaths were reported.
Conclusions/Implications
Medication errors in nursing homes are prevalent. The medical provider and probably
the poison control center should be consulted as soon as possible when people are
aware of administration of medication to the wrong patient, which is considered a
medical emergency until proven otherwise. Public policies should seek for better surveillance
and prompt intervention. Research should be undertaken to limit errors of drug administration
to the wrong nursing home residents.
Keywords
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References
- Health and social services institutions. 2018.(Available at:)http://www.msss.gouv.qc.ca/reseau/etablissements.php#chsldDate accessed: January 24, 2018
- Register of residences for elderly. 2007.(Available at:)http://k10.pub.msss.rtss.qc.ca/K10accueil.aspDate accessed: October 23, 2017
- Family-type resources. 2016.(Available at:)http://www.msss.gouv.qc.ca/professionnels/ressources/ri-rtf/Date accessed: October 16, 2017
- Quebec Health and Social Services. Report on incidents and accidents during the delivery of health care services in Quebec. Quebec Health and Social Services, Quebec, Canada2016
- Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents.J Am Geriatr Soc. 2017; 65: 433-442
- Medication error reporting in nursing homes: Identifying targets for patient safety improvement.Qual Saf Health Care. 2010; 19: 218-222
- Medication errors reported to U.S. Poison control centers, 2000-2012.Clin Toxicol. 2014; 52: 880-888
- Discontinuing inappropriate medication use in nursing home residents: A cluster randomized controlled trial.Ann Intern Med. 2017; 167: 609-617
- The DE-PHARM Project: A pharmacist-driven deprescribing initiative in a nursing facility.Consult Pharm. 2017; 32: 468-478
- Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: A systematic review.Eur J Gen Pract. 2017; 23: 69-77
- 09. Régie de L'assurance Maladie Du Québec 2017.(Available at:)
- Technology and medication errors: Impact in nursing homes.Int J Health Care Qual Assur. 2014; 27: 244-258
- Identifying modifiable barriers to medication error reporting in the nursing home setting.J Am Med Dir Assoc. 2007; 8: 568-574
- Exploratory evaluation of medication classes most commonly involved in nursing home errors.J Am Med Dir Assoc. 2013; 14: 403-408
- Repeat medication errors in nursing homes: Contributing factors and their association with patient harm.Am J Geriatr Pharmacother. 2010; 8: 258-270
- Medication administration errors for older people in long-term residential care.BMC Geriatr. 2011; 11: 82
Medication Incidents Occurring in Long-Term Care. ISMP Canada Safety Bulletin; 2010. p. 1–3. Avaialble at: https://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2010-09-MedIncidentsLTC.pdf. Accessed January 24, 2018.
- Potentially inappropriate medication use in nursing homes: an observational study using the NORGEP-NH criteria.BMC Geriatr. 2017; 17: 220
- Prevalence of potentially inappropriate medication use in older adults living in nursing homes: A systematic review.J Am Med Dir Assoc. 2016; 17: 862.e1-862.e9
- Frailty and potentially inappropriate medication use at nursing home transition.J Am Geriatr Soc. 2017; 65: 2205-2212
- Overdose of atypical antipsychotics: Clinical presentation, mechanisms of toxicity and management.CNS Drugs. 2012; 26: 601-611
- Atypical antipsychotic medication poisoning: An evidence-based consensus guideline for out-of-hospital management.Clin Toxicol. 2007; 45: 918-942
- Antipsychotic clozapine (Clozaril): Myocarditis and cardiovascular toxicity.CMAJ. 2002; 166: 1185-1186
- Clozapine-induced cardiotoxicity: A clinical update.Med J Aust. 2009; 190: 190-192
- Adverse cardiac effects associated with clozapine.J Clin Psychopharmacol. 2005; 25: 32-41
- Patient at Northampton psychiatric hospital died after nurse muddled medication, panel hears. Northampton Chronicle and Echo 2017.(Available at:)
- Mental health patient given wrong medication. NZ Herald 2015.(Available at:)http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11421799Date accessed: January 24, 2018
- Case no. 327413.Quebec Coroner's Office, Quebec, Canada2015
Article info
Publication history
Published online: July 02, 2018
Footnotes
The authors declare no conflicts of interest.
Data Availability: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Identification
Copyright
© 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
