Medication Errors in Nursing Homes - Part 2

- Estimated one adverse drug event occurs perClinical decision support systems provide care
patient per dayguidelines to clinicians and promotes resident safety,
- Treating avoidable events conservatively costeducation and communication. Diagnosis specific
$billions annuallytreatment guidelines (e.g., myocardial infarction plus
- Information technology plays a key role in improvingaspirin or atrial fibrillation plus warfarin) support optimal
resident medication safety Nursing home residentshealth through proactive disease management.
take an average of eight medications per month.Automated resident-specific reminders for drug
One-third of them take nine or more. Despite theallergies, interactions, dosing adjustments and
excellent care provided to these residents, oneevidence-based interventions prevent errors of
avoidable adverse drug related event is estimated toomission. The reminders become a reliably consistent
occur per resident per day at an annual healthcaresurrogate for resources inefficiently spent in
cost of billions. Many events are caused by inefficientretrospective, individual chart reviews. When combined
information systems offering incomplete or inaccuratewith clinical decision support systems CPOE reduce
information to the clinician. Increasing access tomedication errors by 80 percent. Benefits of CPOE
accurate resident specific information empowersand CDSS include:
physicians in perhaps their most important role in- Better documentation for drug usage indications,
long-term care facilities; that of monitoring for inevitableallergies and interactions
drug interactions between diseases, symptoms and- Warning messages triggered by incomplete, incorrect
other drugs in the medication use process. Threeor excessive dosing orders
emerging technologies (EMRs, CPOE and CDSS)- Improvements in therapeutic drug dosing adjustments
actively enlist clinician participation in this ongoing- Avoidance of preventable pharmacotherapeutic
process.organ toxicity
Information Technology (IT) Opportunities- Improved clinician adherence to guideline-based care
Electronic medical records (EMRs) store resident- Positive influence on provider prescribing behavior
specific information electronically thus centralizing- Increased adherence to corollary orders
information and enhancing operational efficiencies forCultural Changes
clinicians and the interdisciplinary team. Other benefitsResidents and families, institutional partners and third
include:party payers now expect system approaches to
- Increased accessibility to and sharing of informationensure policies and procedures follow evolving
- Ongoing clinician maintenance and review of thestandards of care. Cost related quicker and sicker
resident specific medication listhospital discharges into nursing facilities and lawsuits
- Legible clinician documentation consistently compliantinvolving adverse drug events are a few of the
with regulatory languagechange drivers for using these integrated information
- Enhanced systematic surveillance of diseasesystems to improve communication efficiency and
symptom/drug monitoringquality of care. Despite demonstrated improvements
- Updated drug information resourcesusing an EMR, CPOE and CDSS, the long term care
Computerized Physician Order Entry (CPOE)industry has been slow to voluntarily adopt these
CPOE enables electronic entry of clinician orders.technologies. The government is considering mandating
Prescribing medications electronically with an EMR ise-prescribing as requisite for physician Medicare
safer and more reliable than paper based prescribingparticipation with all prescriptions being written
and reduces medication error rates.electronically by 2010.
Clinical Decision Support Systems (CDSS)