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Nursing Home Medication Errors Are Common, but Impact Is Low, Study Finds


The authors leave open the possibility that current reporting systems are not catching the impact of all medication errors. A different study earlier this year found that medical errors, including those that involve medication, caused so many deaths that the CDC should change its reporting methods to account for them.

Reducing errors—including those involving medication—has been a healthcare priority for more than a decade with the rise of quality ratings. But how much do medication errors affect patients? That’s what Joseph Ibrahim, MBBS, FRACP, PhD, and his colleagues at Australia’s Monash University wanted to find out.

After reviewing 11 studies involving medication errors that took place between 2000 and 2015, they found the news is mixed: medication errors are still quite common, but their impact on patients appears to be low.

Or, at least, it’s not showing up in current reporting mechanisms. The authors make a major hedge in their findings, in light of other results published this year, or the possibility that health systems are not connecting medication mix-ups with eventual deaths.

Results were reported Monday in the Journal of the American Geriatrics Society.

The selection of the year 2000 as a starting point is noteworthy. That was the year the Institute of Medicine published To Err Is Human: Building a Safer Health System, the groundbreaking report that found up to 98,000 deaths a year may be the result of medical errors in hospitals, yet these mistakes were not registering in the public consciousness. Medication errors alone were responsible for more deaths than car accidents, according to the report.

Ibrahim and his colleagues were interested in nursing home errors because of the population involved. “Institutionalized older people are particularly vulnerable because of various organizational and individual factors,” they wrote in the abstract.

The studies they examined fell into 3 categories: all medication errors, medication errors related to transfers, and inappropriate medications. They found that medication errors were common, involving between 16% and 27% of all residents in studies of all types of medication errors, and 13% to 31% of residents in studies that examined errors related to transfers.

In a study involving potentially inappropriate medications, 75% of patients were prescribed at least 1 inappropriate medication.

Yet, according to the findings, serious adverse events of the medication errors were surprisingly low: very few were reported—only about 1% of medication errors—and death was rare. “Whether medication errors resulting in serious outcomes are truly infrequent, or are underreported because of the difficulty in ascertaining them, remains to be elucidated to assist in designing safer systems,” the authors wrote.

The Monash authors’ hedge that medication errors may, in fact, be underreported would be in line with a controversial study published earlier this year by researchers at Johns Hopkins University. That study asserted that the CDC’s method of coding the cause of death—which focuses on the underlying medical problem that caused a patient to seek treatment—may miss scores of surgical and medication mistakes.

The Johns Hopkins authors called on the CDC to change the way deaths are reported and said if the system changed, medical errors would vault to the third-leading cause of death, behind cardiovascular disease and cancer. Just last week, the CDC updated its leading causes of death, in which the top 5 causes were unchanged, but “accidents,” which include drug overdoses, are rising instead of falling or holding steady, like the other causes.

Ibrahim characterized the findings as a “first step” toward addressing the issue of medication errors and improving the quality and safety of medications for seniors. In a statement, he said, “Nursing homes should review their systems of care from prescribing to administration. Good practice requires using a team-based approach involving the resident, care and nursing staff, pharmacists, and medical practitioners.”


Ferrah N, Lovell JJ, Ibrahim JE. Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents [published online November 21, 2016]. J Am Geriatr Soc. 2016. DOI: 10.1111/jgs.14683

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