Richard Hansen, PhD — Medication Errors in Nursing Homes
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Richard Hansen, PhD — Medication Errors in Nursing Homes
Medication Errors in Nursing Homes
In 2003, the state legislature mandated that nursing homes in North Carolina report medication errors to a central body. The state contracted with the Cecil G. Sheps Center for Health Services Research at UNC to collect that data. As part of the Medication Error Quality Initiative, Hansen helped develop the Web-based data collection forms. Then in 2006, he helped create a system for reporting individual incidents of medication error that would provide researchers with more detailed information than the summary data that had been reported in the past.
“For instance, if we identify that the reason that most errors are happening is because the package labeling is confusing and it’s leading to consistent errors with a particular product, it’s hard for us to identify that in aggregate data,” Hansen says. “But when they report individual incidents, we can look for patterns and trends with particular drugs, particular personnel, and all kinds of different factors.”
A pilot test for the new system—conducted in twenty-five nursing homes in 2006—revealed a list of medications that are prone to error. Furthermore, Hansen says some of the drugs on the list, such as lorazepam and narcotic painkillers, should not be used in nursing homes in the first place because they are dangerous for older patients as they can cause falls or delirium.
“So not only are they being used more so than they should be, but they are also subject to errors at a higher rate for some reason,” he says.
One hundred and thirty nursing homes have signed up to use the new system, and data is expected in September 2007.
“As far as we know, we are the only state in the country that’s collecting data like this on medication errors in nursing homes,” Hansen says. “There are a lot of people that collect data on hospitals and on community environments, but no one in nursing homes.”