Comprehensive Literature Review of Factors Influencing Medication Safety in Nursing Homes: Using a Systems Model.

OBJECTIVES: The objectives of this review were to identify the work system factors influencing medication safety measures [adverse drug events (ADEs), adverse drug reactions, or medication errors (MEs)], to determine the incidence of ADEs, and describe the most common ADEs in nursing homes (NHs).

METHODS: A comprehensive literature review was conducted using PubMed and CINAHL to identify studies investigating factors that influence ADEs, adverse drug reactions, and MEs in NHs and skilled nursing facilities. An initial search identified related studies over 3 decades (1985-2016). Studies were classified according to Systems Engineering Initiative for Patient Safety model factors.

RESULTS: Sixty studies were included in this review, which identifies 5 categories of work system factors affecting medication safety in NHs: persons (resident and staff), organization, tools and technology, tasks, and environment. The personal characteristics of NH residents included age, number and types of scheduled medications, and number and types of comorbidities. In addition, inadequate nursing staff medication knowledge and training are usually associated with administration MEs. Organizational factors include interprofessional collaboration, physician and pharmacist accessibility, and staff/resident ratio. A high staff number plays an essential role in preventing MEs and fracture incidents. The technology (barcode medication system) and tools (ME-reporting systems, ADE trigger tool, and potentially inappropriate medication criteria) can enhance the detection of MEs and ADEs. Workload and time pressure negatively impact NH staff task performance. Use of an ADE trigger tool by healthcare providers enhanced the ability to identify ADEs more than 50-fold over 6 months. Several environmental characteristics such as staff distraction and interruption negatively influence medication safety in NHs. The incidence rates of ADEs in NHs ranged from 1.89 to 10.8 per 100 resident-months. The most common ADEs were bleeding, thromboembolic events, hypoglycemia, falls, and constipation.

CONCLUSIONS: The Systems Engineering Initiative for Patient Safety model is a useful framework for investigating the factors contributing to ADEs. Multiple work-system factors affect the medication safety of NH residents. A comprehensive study is needed to quantify the influence of various work-system factors on ADEs in NHs.