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Risk Factors for Adverse Drug Events Among Nursing Home Residents
Terry S. Field, DSc;
Jerry H. Gurwitz, MD;
Jerry Avorn, MD;
Danny McCormick, MD, MPH;
Shailavi Jain, RPh;
Marie Eckler, RN, MS, CS, CRRN, GNP;
Marcia Benser, RN, MS;
David W. Bates, MD
Arch Intern Med. 2001;161:1629-1634.
ABSTRACT
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Background In a prospective study of nursing home residents, we found adverse drug
events (ADEs) to be common, serious, and often preventable. To direct prevention
efforts at high-risk residents, information is needed on resident-level risk
factors.
Methods Case-control study nested within a prospective study of ADEs among residents
in 18 nursing homes. For each ADE, we randomly selected a control from the
same home. Data were abstracted from medical records on functional status,
medical conditions, and medication use.
Results Adverse drug events were identified in 410 nursing home residents. Independent
risk factors included being a new resident (odds ratio [OR], 2.8; 95% confidence
interval [CI], 1.5-5.2) and taking anti-infective medications (OR, 4.0; CI,
2.5-6.2), antipsychotics (OR, 3.2; CI, 2.1-4.9), or antidepressants (OR, 1.5;
CI, 1.1-2.3). The number of regularly scheduled medications was associated
with increased risk of ADEs; the OR associated with taking 5 to 6 medications
was 2.0 (CI, 1.2-3.2); 7 to 8 medications, 2.8 (CI, 1.7-4.7); and 9 or more,
3.3 (CI, 1.9-5.6). Taking supplements or nutrients was associated with lower
risk (OR, 0.42; CI, 0.27-0.63). Preventable ADEs occurred in 226 residents.
Independent risk factors included taking opioid medications (OR, 6.6; CI,
2.3-19.3), antipsychotics (OR, 4.0; CI, 2.2-7.3), anti-infectives (OR, 3.0;
CI, 1.6-5.8), antiepileptics (OR, 2.2; CI, 1.1-4.5), or antidepressants (OR,
2.0; CI, 1.1-3.5). Scores of 5 or higher on the Charlson Comorbidity Index
were associated with increased risk of ADEs (OR, 2.6; CI, 1.1-6.0). The number
of regularly scheduled medications was also a risk factor: the OR for 7 to
8 medications was 3.2 (CI, 1.4-6.9) and for 9 or more, 2.9 (CI, 1.3-6.8).
Residents taking nutrients or supplements were at lower risk (OR, 0.27; CI,
0.14-0.50).
Conclusions It is possible to identify nursing home residents at high risk of having
an ADE. Particular attention should be directed at new residents, those with
multiple medical conditions, those taking multiple medications, and those
taking psychoactive medications, opioids, or anti-infective drugs.
INTRODUCTION
HIGH RATES of adverse events occur in the context of providing medical
care in the United States, as documented by the Institute of Medicine's report To Err is Human: Building a Safer Health System.1 Many of these events are adverse drug events (ADEs),
defined to include preventable and nonpreventable events related to the use
of medications. A series of studies2-3
has examined ADEs in hospital settings. However, much less information is
available about these events in nonacute settings. We recently examined the
incidence and preventability of ADEs among the residents of 18 nursing homes
during 1 year and found high rates of ADEs (1.89 ADEs per 100 resident-months,
of which 0.96 were preventable).4 This is not
surprising, given the magnitude and intensity of drug use in nursing homes.
Nursing home residents are frail, elderly, often have difficulty expressing
and ascribing symptoms, and frequently suffer from multiple physical problems—a
constellation of factors that may place them at special risk for developing
problems related to their extensive drug regimens.
Documentation of the ADE problem in the acute care setting has led to
a new focus on prevention within the health care system. Following examples
from the aerospace industry,5 medical safety
is increasingly seen to require system-level modifications rather than more
aggressive identification and punishment of those providers making errors.
One system-level strategy for preventing ADEs in nursing homes may be to identify
residents at high risk so that physicians can consider the resident's level
of risk in their decisions about prescribing, delivering, and monitoring drug
therapy.6 If predictive factors can be identified,
they might also allow providers to identify early symptoms of adverse events
and to respond to them quickly. Therefore, we performed a prospective study
to assess whether resident-level factors are associated with ADEs and preventable
ADEs among nursing home residents.
SUBJECTS AND METHODS
The study was nested within a 12-month study of the incidence and preventability
of ADEs in 18 nursing homes in central and eastern Massachusetts.4 These facilities were recruited from among 81 nursing
homes with more than 50 beds in this geographic region, which were served
by a large long-term care pharmacy provider. The pharmacy provider assisted
in the recruitment of the study nursing homes through invitational letters,
telephone calls, and visits. The mean bed size of participating homes was
149 (SD, 62; range, 72-333). All were certified by Medicare and Medicaid.
Sixty-one percent were proprietary, and the remainder were voluntary nonprofit
nursing homes.
Nursing home enrollment in the study took place in the spring of 1997.
Subjects included all long-stay residents of participating homes at any time
during the 12-months following the facility's enrollment in the study. The
study was approved by the institutional review board of the University of
Massachusetts Medical School, Worcester.
Adverse drug events were defined as injuries
resulting from use of a drug. Preventable ADEs were
those that resulted from a medication error in prescribing, dispensing, administering,
or monitoring. Nonpreventable ADEs are synonymous with adverse drug reactions,
in which no error is involved. Drug-related incidents were identified through
systematic medical chart reviews conducted at 6-week intervals by 3 investigators
(2 nurses and a pharmacist) of each eligible nursing home resident in all
study nursing homes. During medical chart reviews, investigators focused on
several indicators of possible ADEs, including changes and discontinuations
of prescribed medications; unusual laboratory values; changes in symptoms
and new events such as lethargy, confusion, bleeding, falls, and gastrointestinal
problems; and hospitalizations and emergency department visits. To assess
the reliability of case investigators' identification of events, each investigator
reviewed the same set of 10 medical chart components. All 3 investigators
identified the same event in 9 of the 10 charts, with 1 investigator differing
on 1 chart, for greater than 90% agreement. Investigators also encouraged
nursing home staff to report any resident-related events that may have indicated
an ADE, including incidents that may not have seemed immediately obvious as
representing a drug-related event. Reports from nursing home staff accounted
for 14% of the identified events.
Possible events were evaluated by 2 physician reviewers, who classified
them independently as to whether they were ADEs. Classification as an ADE
required an observable impact on the resident's health status or function.
For all events classified as ADEs, reviewers also determined severity and
preventability. Categories of severity were significant, serious, life-threatening, or fatal. Examples of significant events
included falls without fracture, hemorrhage that did not require transfusion
or hospitalization, oversedation, and rashes. Serious events included delirium,
falls with fractures, and hemorrhages requiring transfusion or hospitalization
without hypotension. Life-threatening events included hemorrhage with associated
hypotension, hypoglycemic encephalopathy, and liver failure. Reviewers classified
an ADE as preventable if it was due to an error and was preventable by any
means currently available. Errors were defined according to the stage of pharmaceutical
care (ordering, transcribing, dispensing, administering, or monitoring) and
type. Errors occurred most commonly in the ordering and monitoring stages
of care.4
Disagreements about classification were resolved during consensus meetings.
Reviewers included 2 internist-geriatricians (J.H.G. and J.A.) and 2 general
internists (D.M. and D.W.B.). To assess the reliability of event classification,
100 possible events were randomly drawn, evenly distributed across the 12
months of the study. The initial, preconsensus classifications of the 2 reviewers
were compared, and percent agreement was 89% ( = 0.80).
Cases included all residents who experienced an ADE during the study.
For those residents with multiple ADEs, only the first ADE was included and
all risk factor data were collected as of the date of that event. Among the
2916 subjects who were long-stay residents in participating nursing homes
at some point during the study, ADEs were identified in 410. Of the initial
events among these residents, 230 (56.1%) were classified as significant,
152 (37.1%) as serious, 27 (6.6%) as life-threatening, and 1 (0.2%) was fatal. Table 1 presents the event types: 115 (28.0%)
included a neuropsychiatric component, 52 (12.7%) involved a fall, 49 (12.0%)
had a dermatologic or allergic effect, 46 (11.2%) had an impact on the gastrointestinal
system, 44 (10.7%) included hemorrhage, and 43 (10.5%) included extrapyramidal
symptoms.
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Table 1. Adverse Drug Event (ADE) Types*
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We analyzed preventable ADEs separately. For this portion of the study,
cases included all residents who experienced a preventable event. Risk factor
data were collected as of the date of the first preventable ADE. Of the 410
subjects with an ADE, 226 had at least 1 ADE that was classified as preventable.
For those subjects whose preventable ADE was not the first event, new controls
were randomly selected from residents present in the same nursing home at
the time of the preventable ADE. Of the preventable ADEs, 86 (38.1%) were
classified as significant, 116 (51.3%) as serious, 23 (10.2%) as life-threatening,
and 1 (0.4%) was fatal. Sixty-five (28.8%) included a neuropsychiatric effect,
45 (19.9%) included a fall, 33 (14.6%) involved hemorrhage, and 25 (11.1%)
included a gastrointestinal manifestation (Table 1).
For each case, a control was randomly selected from those long-stay
residents present in the same facility on the date when the event occurred.
Risk factor information was collected as of the date of the event for the
case and control. All residents who had not yet had an ADE at the time of
the event were eligible to serve as controls.
Information on potential risk factors for cases and controls was collected
through medical chart review using standardized forms. Data included sex,
age, and the length of time the resident had been in the facility (classified
as a new resident if the date of admission was within 2 months of the event
date). Burden of illness was assessed using the Charlson Comorbidity Index7 (categorized using scoring as originally developed—0,
1-2, 3-4, and  5) and the Cumulative Illness Rating Scale8
(as a continuous variable). Functional status was measured using the Activities
of Daily Living scale9 (categorized in quartiles)
and the mobility item from the Tinetti Nursing Home Life-Space Diameter10 (results were categorized as mobile or immobile).
Information on medication use at the time of the event included the number
of regularly scheduled medications (categorized in quartiles) and use of any
drug within each of the following drug classes: Alzheimer disease treatments,
antibiotics or anti-infectives, anticoagulants, antidepressants, antigout
therapy, antihistamines, antihyperlipidemics, antineoplastics, antiparkinsonians,
antipsychotics, antiseizure medications, cardiovascular drugs, cholesterol
lowering drugs, diuretics, gastrointestinal medications, hypoglycemics, muscle
relaxants, nonophthalmic topical medications, nonopioid analgesics, nutrients
or supplements, ophthalmics, opioids, osteoporosis medications, respiratory
medications, sedatives or hypnotics, steroids, and thyroid medications. Reliability
of medical chart reviews was assessed through a chart extraction by all 3
investigators on a set of 10 charts. Agreement was 90% or greater on the presence
of comorbid conditions for each condition, on the current use of each drug
category, and on subjects' abilities to carry out 4 of the activities of daily
living. There was more frequent disagreement for 2 of the activities, feeding
and continence.
Analyses began with the calculation of matched odds ratios (ORs) and P values for each categorical variable and paired t tests for the continuous variables of age and the Cumulative
Illness Rating Scale8 score. Subsequently,
separate multivariate models were constructed using all ADEs and preventable
ADEs as the outcome with stepwise conditional logistic regression using commercially
available statistical software.11 Variables
considered for inclusion were those that were significantly associated with
case or control status at P .05 and with prevalence
of at least 5% in either the case or control group. Correlations among potential
risk factors were assessed, and any correlated variables were analyzed in
separate models. Age and sex were forced into all models. Variables were retained
in the model if they were found to have P.05.
We assessed interactions in the optimum models.
Models were built using the categorized Charlson Comorbidity Index7 and the individual diseases from that index. The performance
of the version with the categorized index was superior, so that version was
retained. We hypothesized that 3 particular conditions in the Charlson Comorbidity
Index (dementia, liver disease, and renal disease) may place the residents
at special risk for ADEs,12 and we included
them in our analyses.
RESULTS
Altogether, 410 cases experienced an ADE. Age and sex were similar between
the cases and controls. However, compared with their matched controls, residents
with an ADE were significantly more likely (P<.05)
to be new residents in the facility, to have a score of 5 or higher on the
Charlson Comorbidity Index,7 to take 5 or more
regularly scheduled medications, and to be taking an antibiotic or anti-infective,
anticoagulant, antidepressant, antiseizure drug, antipsychotic, cardiovascular
drug, hypoglycemic, muscle relaxant, and a sedative or hypnotic (Table 2). Cases had higher scores on the
Cumulative Illness Rating Scale8 and were less
likely to take nutrients or supplements.
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Table 2.Characteristics of Residents With Adverse Drug Events and Controls*
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To identify independent correlates of ADEs, we developed a multivariate
model using backward stepwise conditional logistic regression. Possible problems
with collinearity among variables in the model were assessed and none were
found. Interactions were assessed and none were significant. Factors independently
correlated with higher risk of an ADE (Table 3) were: being a new resident (OR, 2.8; CI, 1.5-5.2); taking
5 to 6 (OR, 2.0; CI, 1.2-3.2), 7 to 8 (OR, 2.8; CI, 1.7-4.7), or 9 or more
(OR, 3.3; CI, 1.9-5.6) regularly scheduled medications; and taking an antibiotic
or anti-infective (OR, 4.0; CI, 2.5-6.2), antipsychotic (OR, 3.2; CI, 2.1-4.9),
or antidepressant (OR, 1.5; CI, 1.1-2.3). Taking nutrients or supplements
was protective against ADEs (OR, 0.42; CI, 0.27-0.63).
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Table 3. Independent Risk Factors for Having an Adverse Drug Event
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We also performed univariate analyses to identify variables correlated
with the presence of a preventable ADE (Table 4). Residents with preventable ADEs were significantly more
likely to be a new resident in the home, to have a score of 5 or higher on
the Charlson Comorbidity Index,7 to take 5
or more regularly scheduled medications, and to take antibiotics or anti-infectives,
anticoagulants, antidepressants, antiseizure medications, antipsychotics,
cardiovascular drugs, hypoglycemics, opioids, and sedatives or hypnotics.
They also had higher scores on the Cumulative Illness Rating Scale8 and were less likely to be immobile or to take nutrients
or supplements.
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Table 4. Characteristics of Residents With Preventable Adverse Drug
Events and Controls*
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Independent predictors of a preventable ADE were then identified using
backward stepwise conditional logistic regression (Table 5). Variables independently associated with having a preventable
ADE included having a score of 5 or higher on the Charlson Comorbidity Index7 (OR, 2.6; CI, 1.1-6.0), taking 7 to 8 (OR, 3.2; CI,
1.4-6.9) or 9 or more (OR, 2.9; CI, 1.3-6.8) regularly scheduled medications,
and taking an antibiotic or anti-infective (OR, 3.0; CI, 1.6-5.8), antidepressant
(OR, 2.0; CI, 1.1-3.5), antipsychotic (OR, 4.0; CI, 2.2-7.3), antiseizure
drug (OR, 2.2; CI, 1.1-4.5), or opioid (OR, 6.6; CI, 2.3-19.3). Residents
taking nutrients or supplements were at lower risk (OR, 0.27; CI, 0.14-0.50).
Men were less likely than women were to have a preventable ADE (OR, 0.55;
CI, 0.30-0.99).
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Table 5. Independent Risk Factors for Having a Preventable Adverse
Drug Event
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COMMENT
We found several resident-level factors to be associated with ADEs and
preventable ADEs, and these correlations were much stronger than they appear
to be in the inpatient setting.6 Some of these
factors may be modifiable; in particular, greater numbers of regularly scheduled
medications, antibiotics, and psychoactive drugs were strongly associated
with occurrence of ADEs and preventable ADEs. New residents were at high risk
of having an ADE, but this factor did not attain significance in the multivariate
analysis of risk factors for preventable ADEs (P
= .08). Opioids and antiseizure medications were associated only with preventable
ADEs, as was the number of chronic conditions.
Adverse drug events are a serious problem in the nursing home setting.
Our assessment of the incidence of ADEs in nursing homes found a rate of 1.89
per 100 resident-months, with approximately one half judged to be preventable.4 These events had substantial impact on residents,
with manifestations that included delirium, lethargy, falls, and hemorrhage.
Although many risk factors have been proposed as being associated with
the occurrence of ADEs, relatively little empiric evidence is available, especially
for preventable ADEs.6 The findings of this
study—that many variables are strongly associated with ADEs in the nursing
home setting—contrast remarkably with those of a large recent study6 conducted in inpatients, which found few patient-level
correlates. Among the potential reasons for this is that there may be more
heterogeneity in the level of illness among residents in nursing homes and
that the degree of oversight is much less intense. The drug regimens of nursing
home residents are frequently of long duration and are administered in the
context of frequent changes in physiologic status.
The intent of this study was to better define resident-level factors
associated with high risk of ADEs, with the ultimate goal of supporting interventions
that prevent ADEs and lessen their impact. In the nursing home environment,
physicians may be physically distant from residents, but nursing and support
staff are in daily direct contact. Clearly identifiable factors such as the
type and number of medical conditions and drugs can be easily tracked and
built into monitoring systems for physicians, nurses, and pharmacists.
A major risk factor for ADEs identified in our study was the number
of regularly scheduled medications. Previous studies13-22
have found the number of drugs to be a risk factor for several drug problems
in older adults, although this was not an independent factor in a recent study6 of hospitalized patients of all ages. Among residents
of long-term care facilities, 2 studies13-14
have found the number of drugs to be significantly associated with having
an adverse drug reaction. Most studies performed among community-dwelling15-20
and hospitalized21-22 older populations
have also identified the number of drugs to be predictive of ADEs, with 2
studies23-24 reporting conflicting
results.
Our finding that the number of chronic conditions was associated with
ADEs is also consistent with several previous studies of older adults.16, 19-20,23, 25
Counts of medical problems and number of drugs taken are usually correlated.
A previous study23 that controlled for both
factors simultaneously through multivariate modeling found only the number
of medical diagnoses to be a significant predictor of ADEs. In this study,
both factors were independently associated with preventable ADEs.
We found that residents taking drugs within several specific classes
were at higher risk of having an ADE. Our analyses of the relationship between
drug classes and ADEs did not focus on identifying drugs that were directly
responsible for events. Rather, we were interested in using drugs as markers
to identify residents at high risk by comparing the drug use patterns of residents
who experienced ADEs with those of residents who did not have an event. In
such an analysis, drugs may be serving as proxies for the underlying medical
or functional condition that they are prescribed to treat, or they may be
acting as promoters of reactions to other medications. One example of this
is our finding of a lower risk among residents taking nutrients or supplements.
Use of these agents may be a proxy for the resident's health and functional
status or the caretaking approach of providers. Several of the drugs that
we found associated with ADEs have been highlighted elsewhere14, 26
as having a direct association with drug-related problems, including psychoactive
medications and opioids. However, antibiotics and antiseizure drugs are rarely
pinpointed as risk factors.
These data have several implications for prevention of ADEs. First,
the number of medications given should be minimized and indications reviewed
regularly. Initiation of drugs, especially antibiotics, should be carefully
considered as these medications are not innocuous and some use may be unnecessary.
Perhaps the most exciting possibility is to combine these factors, many of
which are standard tenets of geropharmacology, and use them to target populations
at greatest need for increased levels of scrutiny.
The study had several limitations. The size of the resident population
included in the study and the resulting number of ADEs and preventable ADEs
limited our ability to identify risk factors to moderate-sized risks associated
with factors present in a substantial portion of the population. The study
was based in 18 nursing homes in a specific geographic area. It is possible
that physician prescribing and nursing care patterns specific to this region
could have colored our results. The approach we used to identify and classify
ADEs and preventable ADEs was based on medical record review, followed by
extensive review sessions and independent classification by 2 physicians.
Only those events classified as ADEs with a high confidence level were included.
This limited events to those with high probability and undoubtedly excluded
many actual drug-related problems. Thus, our findings may be biased toward
risk factors for easily identifiable events that are definitely the result
of medication use. In addition, we have not prospectively validated these
results, and the factors may be less predictive in an independent cohort.27
Based on our findings, we recommend that physicians prescribing medications
in nursing homes pay special attention to drug choices in residents with multiple
medical conditions and extensive drug regimens and increase surveillance of
those residents using psychoactive drugs. Nursing staff should carefully monitor
these high-risk residents and those taking antibiotics, opioids, or antiseizure
drugs to identify changes in symptoms that may indicate a drug-related event.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
This study was supported by research grant AG14472 from the National
Institute on Aging, Bethesda, Md.
Presented in part at the 15th International Conference on Pharmacoepidemiology,
International Society for Pharmacoepidemiology, Boston, Mass, August 27, 1999.
We thank the nursing homes participating in this study for their commitment
and dedication to improving the quality of care provided to their residents.
We also thank Mary Ellen Stansky and Jackie Cernieux, MPH, for technical assistance
with the study, and Bessie Petropoulos for assistance with manuscript preparation.
The contents are solely the responsibility of the authors and do not
necessarily reflect the official views of the National Institute on Aging.
Corresponding author and reprints: Terry S. Field, DSc, Meyers Primary
Care Institute, 100 Central St, Worcester, MA 01608 (e-mail: tfield{at}meyersprimary.org).
From the Meyers Primary Care Institute (Drs Field and Gurwitz and Mss
Jain, Eckler, and Benser) and Department of Medicine, University of Massachusetts
Medical School (Drs Field and Gurwitz), Worcester; Divisions of Pharmacoepidemiology
and Pharmacoeconomics (Dr Avorn) and Medicine (Dr Bates), Brigham and Women's
Hospital, and Department of Medicine, Harvard Medical School (Dr Avorn), Boston,
Mass; and Department of Medicine, Division of Social and Community Medicine,
Cambridge Hospital, Cambridge, Mass (Dr McCormick).
REFERENCES
| |
1. Committee on Quality of Health Care in America, Institute of Medicine In: Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human:
Building a Safer Health System. Washington, DC: National Academy Press;
2000.
2. Bates DW, Cullen D, Laird N, et al. Incidence of adverse drug events and potential adverse drug events:
implications for prevention. JAMA. 1995;274:29-34.
ABSTRACT
3. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.
ABSTRACT
4. Gurwitz JH, Field TS, Avorn J, et al. Incidence and preventability of adverse drug events in the nursing
home setting. Am J Med. 2000;109:87-94.
FULL TEXT
|
ISI
| PUBMED
5. Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320:781-785.
FREE FULL TEXT
6. Bates DW, Miller EB, Cullen DJ, et al. Patient risk factors for adverse drug events in hospitalized patients. Arch Intern Med. 1999;159:2553-2560.
FREE FULL TEXT
7. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal
studies: development and validation. J Chronic Dis. 1987;40:373-383.
FULL TEXT
|
ISI
| PUBMED
8. Linn BS, Linn MW, Gurel L. Cumulative Illness Rating Scale. J Am Geriatr Soc. 1968;16:622-626.
ISI
| PUBMED
9. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL: standardized measure
of biological and psychosocial function. JAMA. 1963;185:914-919.
10. Tinetti ME, Ginter SF. The Nursing Home Life-Space Diameter: a measure of extent and frequency
of mobility among nursing home residents. J Am Geriatr Soc. 1990;38:1311-1315.
ISI
| PUBMED
11. Stata Statistical Software. Release 6.0. College Station, Tex: Stata Corp; 1999.
12. Vestal RL, Gurwitz JH. Geriatric pharmacology. In: Carruthers SG, Hoffman BB, Memon KL, Nierenberg DW, eds. Memon and Morrelli's Clinical Pharmacology. 4th ed. New
York, NY: McGraw-Hill; 2000.
13. Cooper JW. Probable adverse drug reactions in a rural geriatric nursing home population:
a four-year study. J Am Geriatr Soc. 1996;44:194-197.
ISI
| PUBMED
14. Soon JA. Assessment of an adverse drug reaction monitoring program in nursing
homes. Can J Hosp Pharm. 1985;38:120-125.
PUBMED
15. Hanlon JT, Schmader KE, Koronkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc. 1997;45:945-948.
ISI
| PUBMED
16. Hutchinson TA, Flegel KM, Kramer MS, Leduc DG, Kong HHP. Frequency, severity and risk factors for adverse drug reactions in
adult out-patients: a prospective study. J Chronic Dis. 1986;39:533-542.
FULL TEXT
|
ISI
| PUBMED
17. Mannesse CK, Derkx FH, de Ridder MA, Man in ‘t Veld AJ, van der Cammen TJ. Adverse drug reactions in elderly patients as contributing factor for
hospital admission: cross sectional study. BMJ. 1997;315:1057-1058.
FREE FULL TEXT
18. Nelson KM, Talbert RL. Drug-related hospital admissions. Pharmacotherapy. 1996;16:701-707.
ISI
| PUBMED
19. Glymonpre RE, Mitenko PA, Sitar DS, Aoki FY, Montgomery PR. Drug-associated hospital admissions in older medical patients. J Am Geriatr Soc. 1988;36:1092-1098.
ISI
| PUBMED
20. Chrischilles EA, Segar ET, Wallace RB. Self-reported adverse drug reactions and related resource use. Ann Intern Med. 1992;117:634-640.
21. Gray SL, Sager M, Lestico MR, Jalaluddin M. Adverse drug events in hospitalized elderly. J Gerontol A Biol Sci Med Sci. 1998;53(1):M59-M63.
22. Carbonin P, Pahor M, Bernabei R, Sgadari A. Is age an independent risk factor of adverse drug reactions in hospitalized
medical patients? J Am Geriatr Soc. 1991;39:1093-1099.
ISI
| PUBMED
23. Gerety MB, Cornell JE, Plichta DT, Eimer M. Adverse events related to drugs and drug withdrawal in nursing home
residents. J Am Geriatr Soc. 1993;41:1326-1332.
ISI
| PUBMED
24. Schneider JK, Mion LC, Frengley JD. Adverse drug reactions in an elderly outpatient population. Am J Hosp Pharm. 1992;49:90-96.
ABSTRACT
25. Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients:
population based review of medical records. BMJ. 2000;320:741-744.
FREE FULL TEXT
26. Fouts M, Janlon J, Peiper C, Perfetto E, Feinberg J. Identification of elderly nursing facility residents at high risk for
drug-related problems. Consultant Pharmacist. 1997;12:1103-1111.
27. Wasson JH, Sox HC, Neff RK, Goldman L. Clinical prediction rules: applications and methodological standards. N Engl J Med. 1985;313:793-799.
ABSTRACT
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Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review
Kuperman et al.
J. Am. Med. Inform. Assoc. 2007;14:29-40.
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Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial
Zermansky et al.
Age Ageing 2006;35:586-591.
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Long-term effects of analgesics in a population of elderly nursing home residents with persistent nonmalignant pain.
Won et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2006;61:165-169.
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Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care
Rochon et al.
CMAJ 2006;174:52-54.
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Risk of adverse drug events by patient destination after hospital discharge
Triller et al.
Am J Health Syst Pharm 2005;62:1883-1889.
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Risk Factors for Adverse Drug Events: A 10-Year Analysis
Evans et al.
The Annals of Pharmacotherapy 2005;39:1161-1168.
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Polypharmacy: A New Paradigm for Quality Drug Therapy in the Elderly?
Gurwitz
Arch Intern Med 2004;164:1957-1959.
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Medication Undertreatment in Assisted Living Settings
Sloane et al.
Arch Intern Med 2004;164:2031-2037.
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Development and Validation of the Medication Regimen Complexity Index
George et al.
The Annals of Pharmacotherapy 2004;38:1369-1376.
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Using Information Technology To Improve the Health Care of Older Adults
Weiner et al.
ANN INTERN MED 2003;139:430-436.
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Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study
Ruths et al.
Qual Saf Health Care 2003;12:176-180.
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"At least Mom will be safe there": the role of resident safety in nursing home quality
Kapp
Qual Saf Health Care 2003;12:201-204.
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Depression and Adverse Drug Reactions Among Hospitalized Older Adults
Onder et al.
Arch Intern Med 2003;163:301-305.
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Preventing Falls in Elderly Persons
Tinetti
NEJM 2003;348:42-49.
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Editorial: Hot Topics in Geriatrics
Morley
J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:M30-36.
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Health Care-Associated Bloodstream Infections: A Change in Thinking
Gaynes
ANN INTERN MED 2002;137:850-851.
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Mental Health Services in Nursing Homes: Psychopharmacologic Interventions in Nursing Homes: What Do We Know and Where Should We Go?
Ryan et al.
Psychiatr. Serv. 2002;53:1407-1413.
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Polypharmacy in Elderly Patients With Diabetes
Good
Diabetes Spectr. 2002;15:240-248.
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Underestimation of Adverse Drug Events in Nursing Home Residents
Lesser et al.
Arch Intern Med 2002;162:609-610.
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