Repeat medication errors in nursing homes: Contributing factors and their association with patient harm

Area of Science:

• Gerontology
• Patient Safety
• Health Services Research

Background:

• Medication errors are frequent in long-term care facilities, leading to preventable patient harm.
• Repeat medication errors, defined as identical events in the same patient, represent a potentially preventable subset of errors.

Purpose of the Study:

• To investigate factors contributing to repeat medication errors in nursing homes.
• To determine the association between repeat medication errors and patient harm.

Main Methods:

• Analysis of medication error reports from North Carolina nursing homes (FY 2006-2008).
• Defined repeat medication errors based on patient characteristics, drug, error type, cause, care phase, and personnel.
• Used multivariate logistic regression to identify factors associated with repeat errors and patient harm.

Main Results:

• Over 37% of reported medication errors were repeats, with wrong dosage being the most frequent type.
• Repeat errors were less common in younger residents (<75 years) and those able to direct their own care.
• Repeat medication errors were associated with a higher likelihood of patient harm (OR = 2.11) compared to nonrepeat errors.

Conclusions:

• Repeat medication errors are a significant issue in nursing homes, posing a greater risk of harm.
• Further research should focus on understanding and mitigating the factors contributing to repeat medication errors to enhance patient safety.