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Adverse drug event, care transitions, chain affiliation, medication errors, skilled nursing facilities



  1. Lane, Sandi J.
  2. Troyer, Jennifer L.
  3. Dienemann, Jacqueline A.
  4. Laditka, Sarah B.
  5. Blanchette, Christopher M.


Background: Older adults are at greatest risk of medication errors during the transition period of the first 7 days after admission and readmission to a skilled nursing facility (SNF).


Purpose: The aim of this study was to evaluate structure- and process-related factors that contribute to medication errors and harm during transition periods at a SNF.


Methodology/Approach: Data for medication errors and potential medication errors during the 7-day transition period for residents entering North Carolina SNFs were from the Medication Error Quality Initiative-Individual Error database from October 2006 to September 2007. The impact of SNF structure and process measures on the number of reported medication errors and harm from errors were examined using bivariate and multivariate model methods.


Findings: A total of 138 SNFs reported 581 transition period medication errors; 73 (12.6%) caused harm. Chain affiliation was associated with a reduction in the volume of errors during the transition period. One third of all reported transition errors occurred during the medication administration phase of the medication use process, where dose omissions were the most common type of error; however, dose omissions caused harm less often than wrong-dose errors did. Prescribing errors were much less common than administration errors but were much more likely to cause harm.


Practice Implications: Both structure and process measures of quality were related to the volume of medication errors.However, process quality measures may play a more important role in predicting harm from errors during the transition of a resident into an SNF. Medication errors during transition could be reduced by improving both prescribing processes and transcription and documentation of orders.