Student Forum The Pharmacist’s Role in Preventing Medication Errors in Older Adults Rupal Kasbekar, Meghan Maples, Ann Bernacchi, Linh Duong, Christine U. Oramasionwu Approximately 1.5 million medication errors occur each year in the United States. Older adults may be at increased risk for these errors as a result of a variety of contributing factors such as inappropriate medication use, polymorbidity, and complexities in managing dosage adjustments for geriatric patients. Pharmacists, as trained medication experts, are uniquely poised to lead efforts to prevent, detect, and resolve medications errors. As the American population continues to age, future pharmacists are likely to play an even greater role in promoting safe and effective medication use in older adults. In this paper, we highlight common settings for medication errors in older individuals, explore tools and solutions for error prevention, and outline the unique role that pharmacists have in preventing medication errors in older adults. Key Words: Beers criteria, Elderly, Geriatric, Medication errors, Medication therapy management, Older adults, Pharmacists, Students. Abbreviations: CMS = Centers for Medicare & Medicaid Services, MAP = Medication-Related Action Plan, MTM = Medication Therapy Management, PMR = Personal Medication Record, START = Screening Tool to Alert Doctors to the Right Treatment, STOPP = Screening Tool of Older Persons for Potentially Inappropriate Prescriptions. Consult Pharm 2014;29:838-42.
Introduction Approximately 1.5 million medication errors occur each year in the United States.1 Older adults may be at increased risk for these errors as a result of a variety of contributing factors such as inappropriate medication use, polymorbidity, and complexities in managing dosage adjustments for geriatric patients.2 The estimated annual cost for adverse drug events related to medication errors among Medicare enrollees 65 years of age and older is approximately $2 billion, almost half of which ($887 million) is a result of preventable medication errors.3 In recent years, federal legislation has heightened awareness surrounding preventable medical errors and reinforced efforts to improve patient safety. In 2008, the Centers for Medicare & Medicaid Services (CMS) announced a policy to stop reimbursements for the treatment of 10 preventable complications of care that result in patient readmission within 30 days of discharge. Moreover, one of the long-term economic goals of the American Recovery and Reinvestment Act of 2009 is to invest in information technologies that reduce medical errors and health-related costs. Pharmacists, as trained medication experts, are uniquely poised to lead efforts to prevent, detect, and resolve medications errors. As the American population continues to age, future pharmacists are likely to play an even greater role in promoting safe and effective medication use in older adults. In this paper, we highlight common settings for medication errors in older adults, briefly review tools to enhance appropriate medication use, and detail the unique role that pharmacists have in preventing medication errors.
Medication Use System and Medication Errors in Older Adults Medication errors are defined as any error that occurs in the medication-use system or process.1 There are four phases in the medication-use process: 1) prescribing, 2) ordering, 3) drug dispensing, and 4) drug administration (Table 1).1 Pharmacists play a fundamental role in preventing errors in all phases of this system. Effective communication between pharmacists and prescribers
838
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Preventing Medication Errors in Older Adults
Table 1. Phases in the Medication-Use Process: Common Sources of Error Phase
Key Elements
Phase 1 Prescribing
Patient information Patient education Communication dynamics Drug information Phase 2 Drug information Ordering Staff education and staffing patterns Quality control Phase 3 Quality control Drug Dispensing Labeling, packaging, and nomenclature of drug Staff education Drug information Phase 4 Drug information Drug Competency Administration Labeling, packing, and nomenclature
Common Failures and Sources of Error → Incomplete clinical information → Inefficient education for patients and/or caregivers → Ineffective communication → Insufficient drug information → Insufficient drug information → Lack of specialized training, insufficient staffing → Inadequate/lack of warning systems → Inconsistent quality control procedures → Lack of standardized dosing systems → Lack of specialized training, insufficient staffing → Inadequate dispensing instructions → Inadequate and/or conflicting drug references → Unclear definition for prescriptive authority → Incorrect and/or unclear medication labels
Source: National Research Council. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press; 2007.
is the first component of the medication-use process (Phase 1: Communication dynamics). Pharmacists are also responsible for ensuring proper labeling and dosing instructions (Phases 3 and 4: Labeling, packaging, and nomenclature of drug). Finally, drug information, a specialty for pharmacists, is a component of all four phases (Phases 1-4: Drug information). Student pharmacists are trained in this area, as it is a substantial component of all pharmacy school curricula. Older patients may be more susceptible to errors in the medication-use system because of a high concurrent medication use (polypharmacy) and the complexities of multiple providers treating concurrent comorbid conditions that are often associated with aging.2 Medication errors can result in adverse consequences for these patients, and inappropriate medication use by older adults has been linked to negative health outcomes, namely increased emergency hospitalizations because of adverse drug events as well as increased health care costs.4
Common Settings for Medication Errors in Older Adults Medication discrepancies in older adults often occur during transitions of care, including hospital admission, hospital discharge, and transfer to other facilities such as long-term care and assisted living facilities.5 Kwan and colleagues recently conducted a systematic review of hospital-based medication-reconciliation interventions at transition points of care to and from the acute care setting.5 Eighteen studies were included in the review, representing 20 interventions. Patients older than 75 years of age were considered to be at high risk for medicationrelated errors. The authors highlighted the finding that medication-reconciliation interventions led by pharmacists were most likely to prevent medication errors and adverse drug events during care transitions. Medication errors in long-term residential care facilities are also quite common.6,7 In 2003, North Carolina nursing facilities were mandated to report all actual and
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Student Forum
Table 2. Additional Resources for Preventing Medication Errors Organization
Resource
Links for Additional Information
Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Initiative: Building Foundations, Reducing Risk
www.ahrq.gov/research/findings/ final-reports/pscongrpt/index.html
Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov/professionals/qualityMedications at Transitions and Clinical Handoffs (MATCH) Toolkit patient-safety/patient-safety-resources/ resources/match/index.html for Medication Reconciliation
American Society of HealthSystem Pharmacists (ASHP)
Guidelines and Policy Statements on Medication Misadventures
www.ashp.org/menu/PracticePolicy/ PolicyPositionsGuidelinesBestPractices/ BrowsebyTopic/Medication Misadventures.aspx
Institute for Safe Medication Practices (ISMP)
Medication Safety Tools and Resources
www.ismp.org/tools/
potential medication errors.6 According to cross-sectional analyses of 294 North Carolina nursing facilities, a mean of 24.9 medication errors per 100 patient beds occurred between 2006 and 2008; almost two-thirds (70%) of these were caused by human error. The study authors noted that increasing age (75 years of age and older) and cognitive impairment were each independently associated with an increased risk of repeated medication errors among nursing facility residents (P < 0.001 for each association). A separate systematic review by Chhabra and colleagues focused on medication reconciliation as a mechanism for preventing medication errors during care transitions to and from long-term care settings.8 They reviewed seven studies that were conducted in various long-term care facilities, including nursing homes, skilled nursing facilities, residential care facilities, homes for the aged, assisted living facilities, and hospice care. Similar to the systematic review by Kwan and colleagues, Chhabra and colleagues emphasized the importance of the pharmacist’s role in leading effective medication reconciliation efforts and resolving medication discrepancies for older adults. Collectively, these findings underscore the pharmacist’s ability to implement systems to reduce the incidence of medication errors in these settings.
840
Solutions for Pharmacists to Reduce Medication Errors Pharmacists can use a variety of screening tools and resources to promote proper medication use in geriatric patients. One well-known tool to prevent inappropriate medication use is the Beers criteria, a list of medications that are associated with potential risks in older adults.9 These criteria, commonly known as the Beers list, have been revised and updated in 2012. They are intended to serve as a guideline and educational tool for medication management in older adults, not as a substitute for clinical judgment.9 Other recent and more comprehensive tools include the STOPP (Screening Tool of Older Persons for potentially inappropriate Prescriptions) and START (Screening Tool to Alert doctors to the Right Treatment) criteria.10 Together, the STOPP/START screening tools offer a more comprehensive method to identify potentially inappropriate medications, as well as identify underprescribed medications, in various geriatric care settings. Additional resources to prevent medication errors are listed in Table 2. Integrating new technology into the medication-use process can also help reduce errors and improve patient safety. Examples of technology include electronic
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Preventing Medication Errors in Older Adults
prescription records, computerized physician order-entry systems, electronic drug utilization reviews, and barcoding. Barcoding has been shown to be effective in preventing medication administration errors among residents in long-term care facilities.7 This system involves internal checks to promote proper medication administration based on identifying the correct patient, medication, time, dose, quantity, and date.7 Szczepura and colleagues performed a prospective study in England to measure the incidence of medication errors among older adults living in residential and nursing facilities.7 Of the 188,249 medication administrations that occurred among 345 residents, 2,289 (1.2%) of potential administration errors were averted. The barcode medication-administration system was centrally managed by an external pharmacy. This study demonstrates that health information technology can be effective in capturing and preventing medication errors, even in settings where a pharmacist is not available onsite. Medication therapy management (MTM) is one of the most effective services for pharmacists to reduce medication errors. Pharmacists counsel patients to enhance their knowledge of their medication regimens, improve adherence, and detect drug interactions or improper prescribing. First introduced in 2003 through the Medicare Prescription Drug Improvement and Modernization Act, MTM aims to improve patient safety by assessing and evaluating patients’ medication therapy. MTM is divided into five components: medication therapy review (MTR), personal medication record (PMR), medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up. MTR consists of a collection of medical conditions and is essential to identifying medication errors. A PMR is a comprehensive list of all medications including prescription drugs, over-thecounter drugs, and herbal products. This record can help to identify potential errors with both prescription and nonprescription medications. A MAP is then created, in which the pharmacist creates a plan using patient input to improve adherence. If necessary, a patient intervention and/or referral to a health provider is made to correct errors and improve outcomes. Finally, documentation and follow-up for the MTM is provided. This component is
used as a measure of maintenance and continuous patient monitoring. Of note, CMS requires that all Medicare Part D (drug coverage) plan sponsors incorporate an MTM program into their plan’s benefit structure. MTM might often be perceived as an outpatient service; however, these services can also be applied to the long-term care setting, as Medicare beneficiaries who reside in long-term care facilities are eligible for both Medicare Part D and MTM services. MTM interventions in this setting may need to be adapted based on the level of patient cognition, involvement of caregivers, access to medical records, and communication with facility staff.
Conclusion Medication errors and inappropriate medication use remain important—but potentially preventable—problems for older persons. Student pharmacists are uniquely poised to play a key role in preventing medication errors and improving health care delivery for this growing patient population.
Rupal Kasbekar is a third-year PharmD candidate, University of North Carolina (UNC) Eshelman School of Pharmacy, Chapel Hill, North Carolina. Meghan Maples is a third-year PharmD candidate, UNC Eshelman School of Pharmacy. Ann Bernacchi is a third-year PharmD candidate, UNC Eshelman School of Pharmacy. Linh Duong is a third-year PharmD candidate, UNC Eshelman School of Pharmacy. Christine U. Oramasionwu, PhD, PharmD, BCPS, is an assistant professor, UNC Eshelman School of Pharmacy, Chapel Hill. For correspondence: Christine U. Oramasionwu, PhD, PharmD, UNC Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Campus Box 7573, Chapel Hill, NC 27599-7355; Phone: 919-843-4071; Fax: 919-966-8486; E-mail: [email protected]. Acknowledgments: The authors would like to thank Joshua Toliver, PharmD, for his assistance in preparing this manuscript. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.838.
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Student Forum References 1. National Research Council. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press; 2007. 2. Fialova D, Onder G. Medication errors in elderly people: contributing factors and future perspectives. Br J Clin Pharmacol 2009;67:641-5. 3. Field TS, Gilman BH, Subramanian S et al. The costs associated with adverse drug events among older adults in the ambulatory setting. Med Care 2005;43:1171-6. 4. Budnitz DS, Lovegrove MC, Shehab N et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:2002-12. 5. Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397-403.
842
6. Crespin DJ, Modi AV, Wei D et al. Repeat medication errors in nursing homes: contributing factors and their association with patient harm. Am J Geriatr Pharmacother 2010;8:258-70. 7. Szczepura A, Wild D, Nelson S. Medication administration errors for older people in long-term residential care. BMC Geriatr 2011;11:82. 8. Chhabra PT, Rattinger GB, Dutcher SK et al. Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 2012;8:60-75. 9. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616-31. 10. Gallagher P, Ryan C, Byrne S et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008;46:72-83.
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Introduction Approximately 1.5 million medication errors occur each year in the United States.1 Older adults may be at increased risk for these errors as a result of a variety of contributing factors such as inappropriate medication use, polymorbidity, and complexities in managing dosage adjustments for geriatric patients.2 The estimated annual cost for adverse drug events related to medication errors among Medicare enrollees 65 years of age and older is approximately $2 billion, almost half of which ($887 million) is a result of preventable medication errors.3 In recent years, federal legislation has heightened awareness surrounding preventable medical errors and reinforced efforts to improve patient safety. In 2008, the Centers for Medicare & Medicaid Services (CMS) announced a policy to stop reimbursements for the treatment of 10 preventable complications of care that result in patient readmission within 30 days of discharge. Moreover, one of the long-term economic goals of the American Recovery and Reinvestment Act of 2009 is to invest in information technologies that reduce medical errors and health-related costs. Pharmacists, as trained medication experts, are uniquely poised to lead efforts to prevent, detect, and resolve medications errors. As the American population continues to age, future pharmacists are likely to play an even greater role in promoting safe and effective medication use in older adults. In this paper, we highlight common settings for medication errors in older adults, briefly review tools to enhance appropriate medication use, and detail the unique role that pharmacists have in preventing medication errors.
Medication Use System and Medication Errors in Older Adults Medication errors are defined as any error that occurs in the medication-use system or process.1 There are four phases in the medication-use process: 1) prescribing, 2) ordering, 3) drug dispensing, and 4) drug administration (Table 1).1 Pharmacists play a fundamental role in preventing errors in all phases of this system. Effective communication between pharmacists and prescribers
838
The Consultant Pharmacist december 2014 Vol. 29, No. 12
Preventing Medication Errors in Older Adults
Table 1. Phases in the Medication-Use Process: Common Sources of Error Phase
Key Elements
Phase 1 Prescribing
Patient information Patient education Communication dynamics Drug information Phase 2 Drug information Ordering Staff education and staffing patterns Quality control Phase 3 Quality control Drug Dispensing Labeling, packaging, and nomenclature of drug Staff education Drug information Phase 4 Drug information Drug Competency Administration Labeling, packing, and nomenclature
Common Failures and Sources of Error → Incomplete clinical information → Inefficient education for patients and/or caregivers → Ineffective communication → Insufficient drug information → Insufficient drug information → Lack of specialized training, insufficient staffing → Inadequate/lack of warning systems → Inconsistent quality control procedures → Lack of standardized dosing systems → Lack of specialized training, insufficient staffing → Inadequate dispensing instructions → Inadequate and/or conflicting drug references → Unclear definition for prescriptive authority → Incorrect and/or unclear medication labels
Source: National Research Council. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press; 2007.
is the first component of the medication-use process (Phase 1: Communication dynamics). Pharmacists are also responsible for ensuring proper labeling and dosing instructions (Phases 3 and 4: Labeling, packaging, and nomenclature of drug). Finally, drug information, a specialty for pharmacists, is a component of all four phases (Phases 1-4: Drug information). Student pharmacists are trained in this area, as it is a substantial component of all pharmacy school curricula. Older patients may be more susceptible to errors in the medication-use system because of a high concurrent medication use (polypharmacy) and the complexities of multiple providers treating concurrent comorbid conditions that are often associated with aging.2 Medication errors can result in adverse consequences for these patients, and inappropriate medication use by older adults has been linked to negative health outcomes, namely increased emergency hospitalizations because of adverse drug events as well as increased health care costs.4
Common Settings for Medication Errors in Older Adults Medication discrepancies in older adults often occur during transitions of care, including hospital admission, hospital discharge, and transfer to other facilities such as long-term care and assisted living facilities.5 Kwan and colleagues recently conducted a systematic review of hospital-based medication-reconciliation interventions at transition points of care to and from the acute care setting.5 Eighteen studies were included in the review, representing 20 interventions. Patients older than 75 years of age were considered to be at high risk for medicationrelated errors. The authors highlighted the finding that medication-reconciliation interventions led by pharmacists were most likely to prevent medication errors and adverse drug events during care transitions. Medication errors in long-term residential care facilities are also quite common.6,7 In 2003, North Carolina nursing facilities were mandated to report all actual and
The Consultant Pharmacist december 2014 Vol. 29, No. 12
839
Student Forum
Table 2. Additional Resources for Preventing Medication Errors Organization
Resource
Links for Additional Information
Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Initiative: Building Foundations, Reducing Risk
www.ahrq.gov/research/findings/ final-reports/pscongrpt/index.html
Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov/professionals/qualityMedications at Transitions and Clinical Handoffs (MATCH) Toolkit patient-safety/patient-safety-resources/ resources/match/index.html for Medication Reconciliation
American Society of HealthSystem Pharmacists (ASHP)
Guidelines and Policy Statements on Medication Misadventures
www.ashp.org/menu/PracticePolicy/ PolicyPositionsGuidelinesBestPractices/ BrowsebyTopic/Medication Misadventures.aspx
Institute for Safe Medication Practices (ISMP)
Medication Safety Tools and Resources
www.ismp.org/tools/
potential medication errors.6 According to cross-sectional analyses of 294 North Carolina nursing facilities, a mean of 24.9 medication errors per 100 patient beds occurred between 2006 and 2008; almost two-thirds (70%) of these were caused by human error. The study authors noted that increasing age (75 years of age and older) and cognitive impairment were each independently associated with an increased risk of repeated medication errors among nursing facility residents (P < 0.001 for each association). A separate systematic review by Chhabra and colleagues focused on medication reconciliation as a mechanism for preventing medication errors during care transitions to and from long-term care settings.8 They reviewed seven studies that were conducted in various long-term care facilities, including nursing homes, skilled nursing facilities, residential care facilities, homes for the aged, assisted living facilities, and hospice care. Similar to the systematic review by Kwan and colleagues, Chhabra and colleagues emphasized the importance of the pharmacist’s role in leading effective medication reconciliation efforts and resolving medication discrepancies for older adults. Collectively, these findings underscore the pharmacist’s ability to implement systems to reduce the incidence of medication errors in these settings.
840
Solutions for Pharmacists to Reduce Medication Errors Pharmacists can use a variety of screening tools and resources to promote proper medication use in geriatric patients. One well-known tool to prevent inappropriate medication use is the Beers criteria, a list of medications that are associated with potential risks in older adults.9 These criteria, commonly known as the Beers list, have been revised and updated in 2012. They are intended to serve as a guideline and educational tool for medication management in older adults, not as a substitute for clinical judgment.9 Other recent and more comprehensive tools include the STOPP (Screening Tool of Older Persons for potentially inappropriate Prescriptions) and START (Screening Tool to Alert doctors to the Right Treatment) criteria.10 Together, the STOPP/START screening tools offer a more comprehensive method to identify potentially inappropriate medications, as well as identify underprescribed medications, in various geriatric care settings. Additional resources to prevent medication errors are listed in Table 2. Integrating new technology into the medication-use process can also help reduce errors and improve patient safety. Examples of technology include electronic
The Consultant Pharmacist december 2014 Vol. 29, No. 12
Preventing Medication Errors in Older Adults
prescription records, computerized physician order-entry systems, electronic drug utilization reviews, and barcoding. Barcoding has been shown to be effective in preventing medication administration errors among residents in long-term care facilities.7 This system involves internal checks to promote proper medication administration based on identifying the correct patient, medication, time, dose, quantity, and date.7 Szczepura and colleagues performed a prospective study in England to measure the incidence of medication errors among older adults living in residential and nursing facilities.7 Of the 188,249 medication administrations that occurred among 345 residents, 2,289 (1.2%) of potential administration errors were averted. The barcode medication-administration system was centrally managed by an external pharmacy. This study demonstrates that health information technology can be effective in capturing and preventing medication errors, even in settings where a pharmacist is not available onsite. Medication therapy management (MTM) is one of the most effective services for pharmacists to reduce medication errors. Pharmacists counsel patients to enhance their knowledge of their medication regimens, improve adherence, and detect drug interactions or improper prescribing. First introduced in 2003 through the Medicare Prescription Drug Improvement and Modernization Act, MTM aims to improve patient safety by assessing and evaluating patients’ medication therapy. MTM is divided into five components: medication therapy review (MTR), personal medication record (PMR), medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up. MTR consists of a collection of medical conditions and is essential to identifying medication errors. A PMR is a comprehensive list of all medications including prescription drugs, over-thecounter drugs, and herbal products. This record can help to identify potential errors with both prescription and nonprescription medications. A MAP is then created, in which the pharmacist creates a plan using patient input to improve adherence. If necessary, a patient intervention and/or referral to a health provider is made to correct errors and improve outcomes. Finally, documentation and follow-up for the MTM is provided. This component is
used as a measure of maintenance and continuous patient monitoring. Of note, CMS requires that all Medicare Part D (drug coverage) plan sponsors incorporate an MTM program into their plan’s benefit structure. MTM might often be perceived as an outpatient service; however, these services can also be applied to the long-term care setting, as Medicare beneficiaries who reside in long-term care facilities are eligible for both Medicare Part D and MTM services. MTM interventions in this setting may need to be adapted based on the level of patient cognition, involvement of caregivers, access to medical records, and communication with facility staff.
Conclusion Medication errors and inappropriate medication use remain important—but potentially preventable—problems for older persons. Student pharmacists are uniquely poised to play a key role in preventing medication errors and improving health care delivery for this growing patient population.
Rupal Kasbekar is a third-year PharmD candidate, University of North Carolina (UNC) Eshelman School of Pharmacy, Chapel Hill, North Carolina. Meghan Maples is a third-year PharmD candidate, UNC Eshelman School of Pharmacy. Ann Bernacchi is a third-year PharmD candidate, UNC Eshelman School of Pharmacy. Linh Duong is a third-year PharmD candidate, UNC Eshelman School of Pharmacy. Christine U. Oramasionwu, PhD, PharmD, BCPS, is an assistant professor, UNC Eshelman School of Pharmacy, Chapel Hill. For correspondence: Christine U. Oramasionwu, PhD, PharmD, UNC Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Campus Box 7573, Chapel Hill, NC 27599-7355; Phone: 919-843-4071; Fax: 919-966-8486; E-mail: [email protected]. Acknowledgments: The authors would like to thank Joshua Toliver, PharmD, for his assistance in preparing this manuscript. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.838.
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Student Forum References 1. National Research Council. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press; 2007. 2. Fialova D, Onder G. Medication errors in elderly people: contributing factors and future perspectives. Br J Clin Pharmacol 2009;67:641-5. 3. Field TS, Gilman BH, Subramanian S et al. The costs associated with adverse drug events among older adults in the ambulatory setting. Med Care 2005;43:1171-6. 4. Budnitz DS, Lovegrove MC, Shehab N et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:2002-12. 5. Kwan JL, Lo L, Sampson M et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397-403.
842
6. Crespin DJ, Modi AV, Wei D et al. Repeat medication errors in nursing homes: contributing factors and their association with patient harm. Am J Geriatr Pharmacother 2010;8:258-70. 7. Szczepura A, Wild D, Nelson S. Medication administration errors for older people in long-term residential care. BMC Geriatr 2011;11:82. 8. Chhabra PT, Rattinger GB, Dutcher SK et al. Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 2012;8:60-75. 9. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616-31. 10. Gallagher P, Ryan C, Byrne S et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008;46:72-83.
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