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Medication-Related Adverse Events in Nursing Homes

Center for Clinical Standards and Quality/Survey & Certification Group Ref: S&C: 15-47 NH


In February 2014, the Office of the Inspector General (OIG) released a report, "Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries." The OIG found that one in three skilled nursing facility (SNF) residents were harmed by an adverse event or temporary harm event within the first 35 days of a SNF stay, and 37 percent of the adverse events were related to medication. The second most frequent cause of medication related adverse events was excessive bleeding related to anticoagulant use, causing harm ranging from hospitalization to death. These findings are further supported by ProPublica data reported in a 2015 Washington Post article that stated, "...from 2011 to 2014, at least 165 nursing home residents were hospitalized or died after errors involving Coumadin or its generic version, warfarin."

The CMS recognizes the necessity of anticoagulant therapy for many conditions in nursing home residents, but its narrow therapeutic range requires effective monitoring systems to ensure safe administration and to achieve the desired effect.

Focused Survey on Medication Safety Systems

The CMS has developed and begun pilot testing the Focused Survey on Medication Safety Systems to look at nursing home practice around high-risk and problem-prone medications, such as Coumadin. Objectives of the Focused Survey on Medication Safety Systems are to:

  • Identify preventable adverse drug events that have occurred or may occur;

  • Determine whether facilities identify residents' risk factors for adverse drug events and implement individualized interventions to eliminate or mitigate those risk factors; and

  • Determine if the facility has implemented effective systems to prevent adverse drug events, as well as recognize and respond to adverse drug events that occur in order to minimize harm for the individual and prevent recurrence of the event.

Adverse Drug Event Trigger Tool

The CMS collaborated with the Agency for Healthcare Research & Quality (AHRQ) and the OIG to develop a tool, which includes potentially preventable medication-related adverse events, risk factors, triggers, and probes to assist surveyors in investigating actual and potential adverse events and to evaluate whether systems are in place to prevent medication-related adverse events. The trigger tool is one of several tools in use for the pilot focused survey.

The CMS is releasing the draft Adverse Drug Event Trigger Tool to assist surveyors as they investigate medication-related adverse events and to assess whether facilities have implemented effective systems to prevent adverse drug events. Use of this draft tool is not mandatory but may aid surveyors in assessing compliance around medication issues during standard and complaint surveys. Nursing home providers also may find it useful as a risk management tool. The draft "Adverse Drig Event Trigger Tool" PDF is available on the CMS Nursing Home Quality Assurance and Performance Improvement (QAPI) website.


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