Sandra B. Greene

The Association of Changes in Local Health Department Resources With Changes in State-Level Health Outcomes

We explored the association between changes in local health department (LHD) resource levels with changes in health outcomes via a retrospective cohort study. We measured changes in expenditures and staffing reported by LHDs on the 1997 and 2005 National Association of County and City Health Officials surveys and assessed changes in state-level health outcomes with the Americas Health Rankings reports for those years. We used pairwise correlation and multivariate regression to analyze the association of changes in LHD resources with changes in health outcomes. Increases in LHD expenditures were significantly associated with decreases in infectious disease morbidity at the state level (P = .037), and increases in staffing were significantly associated with decreases in cardiovascular disease mortality (P = .014), controlling for other factors.

Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system

Objective: To describe the implementation and evaluation of a web-based medication error reporting system. Design: Evaluation study. Setting: Long-term care. Participants: 25 nursing homes in the US state of North Carolina. Intervention: Detailed information about all medication errors occurring in a facility during a 1 year period was entered into a web-based reporting system. An evaluation survey was conducted to assess usability and the potential for the system to prevent errors. Main outcome measures: Number and specific characteristics of medication errors reported. A survey evaluating ease of use of the system and whether the participants thought it would help improve medication safety. Results: 23 (92%) sites entered 631 error reports for 2731 discrete error instances when weighted by the number of times the errors were repeated. 51 (8%) errors were classified as having a serious patient impact requiring monitoring/intervention or worse. The most common errors were dose omission (203, 32%), overdose (91, 14%), underdose (43, 7%), wrong patient (38, 6%), wrong product (38, 6%), and wrong strength (38, 6%). Errors most commonly occurred during medication administration (296, 47%) and were attributed to basic human error (402, 48%). Seven drugs were implicated in a third (175, 28%) of all errors: lorazepam, oxycodone, warfarin, furosemide, hydrocodone, insulin and fentanyl. 20 sites (86% of respondents) completed the evaluation survey and participants found the system easy to use and thought it would increase accuracy of reporting and improve patient safety. Conclusions: The web-based medication error reporting system was easy to use, with strong indications that it would be a valuable tool for preventing future errors.

Repeat medication errors in nursing homes: Contributing factors and their association with patient harm.

BACKGROUND Medication errors are highly prevalent in long-term care facilities and are responsible for preventable injury. Repeat medication errors, or identical events occurring multiple times in the same patient, may be particularly preventable. OBJECTIVES This study assessed the factors that contribute to repeat medication errors and the association between repeat medication errors and patient harm. METHODS In this cross-sectional analysis, medication error reports submitted by licensed nursing homes to North Carolinas Medication Error Quality Initiative-Individual Error Web-based incident reporting system were analyzed for fiscal years 2006-2008. When reporting errors, the sites were asked whether the event was identically repeated within the same patient. Repeat medication errors were defined as identical events in terms of patient characteristics, drug involved, error type, potential cause, phase of the medication care process, and personnel involved. Repeat errors were compared with nonrepeat errors. Multivariate logistic regression was used to explore whether certain patient or error characteristics were related to a higher likelihood of repeat errors, and a similar analysis was used to explore whether repeat errors were related to patient harm. RESULTS Of the total 15,037 errors reported by 294 unique nursing homes, 5615 (37.3%) were repeated one or more times. Among the repeat errors, the associated event within each error was repeated a mean (SD) of 10.7 (14.3) times. Wrong dosage (65.1% [3654/5615]) and wrong administration (10.2% [571/5615]) were the most frequent repeated events. In multivariate analysis, repeat errors occurred less frequently among younger residents (aged <75 years) than among older residents (aged >or=75 years) (odds ratio [OR] = 0.85; 95% CI, 0.79-0.93) and among residents able to direct their own care compared with cognitively impaired residents (OR = 0.87; 95% CI, 0.81-0.95). Patient harm was reported in only 1.2% (68/5615) of repeat errors and 0.6% (55/9422) of non-repeat errors. A multivariate analysis of patient harm found that repeat errors were more likely to be harmful than were nonrepeat errors (OR = 2.11; 95% CI, 1.43-3.11). CONCLUSIONS Repeat medication errors in nursing homes are a common occurrence and have greater odds of being associated with harm than do nonrepeat errors. Future patient-safety research should focus on factors related to repeat errors.

Medication Errors During Patient Transitions into Nursing Homes: Characteristics and Association With Patient Harm

BACKGROUND Patients transitioning to a nursing home from their home or other facility are at high risk for medication errors. OBJECTIVE Our aim was to describe characteristics of medication errors occurring during transitions to nursing homes, to compare characteristics of transition errors with errors not involving a transition, and to evaluate the impact of these errors on patient harm. METHODS This was a cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2007 through 2009. Bivariate associations between errors in transition with patient factors, error-related factors, reported causes of errors, and impact on patients were tested using a χ(2) test. Multivariate logistic regression explored whether medication errors during transitions were more harmful than errors not occurring during transitions. Patient-related factors included in the model were age, sex, and cognitive ability. Error-related factors were primary type of error, process phase when error began, primary personnel involved, and an indicator for repeat error. RESULTS A total of 27,759 individual medication error incidents were reported over a 3-year period in North Carolina nursing homes. Of these errors, 2919 incidents (11%) involved a patient transitioning to a nursing home. Errors involved in transitions were found to have higher odds of patient harm compared with errors not involved in transitions (odds ratio = 1.85; 95% CI, 1.30-2.63). Staff communication, order transcription, medication availability, pharmacy issues, and name confusion were particularly important contributors to medication errors during transitions (P < 0.05 for comparison with nontransition errors). CONCLUSIONS Transitions across care settings introduce risk for patient harm, and medication errors are an important area for improvement during transitions.

Access to health care in a southern rural community

This case study of utilization of health care services in a rural southern community is the first of a series of reports dealing with access to care in this community. The most striking findings were the low utilization of physician and dental services compared with national standards (particularly by the black population) and the infrequent use of private physicians by blacks. Possible explanations for these findings arc the short time interval since integration of services after Medicare and Medicaid legislation, the short supply of primary care physicians, especially black, in this community, and the reluctance of white physicians to accept Medicaid patients. We postulate that while employment and social mobility have improved greatly for blacks, established methods of medical and dental practice have changed slowly.

Exploratory Evaluation of Medication Classes Most Commonly Involved in Nursing Home Errors

BACKGROUND Medication errors may potentially pose significant risk of harmful outcomes in vulnerable nursing home residents. Current literature lacks data regarding the drug classes most frequently involved in errors in this population and their risk relative to underlying drug class utilization rates. OBJECTIVES This study (1) describes the frequency and error characteristics for the drug classes most commonly involved in medication errors in nursing homes, and (2) examines the correlation between drug class utilization rates and their involvement in medication errors in nursing home residents. DESIGN A cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2010 to 2011 was conducted. PARTICIPANTS All nursing home residents in the state of North Carolina. MAIN MEASURES The 10 drug classes most frequently involved in medication errors were identified. Characteristics and patient impact of these medication errors were further examined as frequencies and proportions within each drug class. Medication error data were combined with data from the 2004 National Nursing Home Survey to capture nationally representative estimates of medication use by drug class in nursing home patients. The correlation between medication utilization and error involvement was assessed. RESULTS There were 32,176 individual medication errors reported to Medication Error Quality Initiative in years 2010-2011. The 10 drug classes most commonly involved in medication errors were analgesics (12.27%), anxiolytics/sedative/hypnotics (8.39%), antidiabetic agents (5.86%), anticoagulants (5.04%), anticonvulsants (4.05%), antidepressants (4.05%), laxatives (3.13%), ophthalmic preparations (2.77%), antipsychotics (2.47%), and diuretics (2.34%). The correlation between utilization and medication error involvement was not statistically significant (P value for spearman correlation coefficient = .88), suggesting certain drug classes are more likely to be involved in medication errors in nursing home patients regardless of the extent of their use. CONCLUSIONS The drug classes frequently and disproportionately involved in errors in nursing homes include anxiolytics/sedatives/hypnotics, antidiabetic agents, anticoagulants, anticonvulsants, and ophthalmic preparations. Better understanding of the causes and prevention strategies to reduce these errors may improve nursing home patient safety.

Women's intentions to receive cervical cancer screening with primary human papillomavirus testing.

We explored the potential impact of human papillomavirus (HPV) testing on womens intentions to be screened for cervical cancer in a cohort of Canadian women. Participants aged 25–65 years from an ongoing trial were sent a questionnaire to assess womens intentions to be screened for cervical cancer with HPV testing instead of Pap smears and to be screened every 4 years or after 25 years of age. We created scales for attitudes about HPV testing, perceived behavioral control, and direct and indirect subjective norms. Demographic data and scales that were significantly different (p < 0.1) between women who intended to be screened with HPV and those who did not intend were included in a stepwise logistic regression model. Of the 2,016 invitations emailed, 1,538 were received, and 981 completed surveys for a response rate of 63% (981/1,538). Eighty‐four percent of women (826/981) responded that they intended to attend for HPV‐based cervical cancer screening, which decreased to 54.2% when the screening interval was extended, and decreased further to 51.4% when screening start was delayed to age of 25. Predictors of intentions to undergo screening were attitudes (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.15, 1.30), indirect subjective norms (OR: 1.02; 95% CI: 1.01, 1.03) and perceived behavioral control (OR: 1.16; 95% CI: 1.10; 1.22). Intentions to be screened for cervical cancer with HPV testing decreased substantially when the screening interval was extended and screening started at age of 25. Use of primary HPV testing may optimize the screening paradigm, but programs should ensure robust planning and education to mitigate any negative impact on screening attendance rates.

Medication error reporting in nursing homes: identifying targets for patient safety improvement

Background Legislation enacted in the US State of North Carolina in 2003 requires all licenced nursing homes to report all medication errors. In 2007, nursing homes were encouraged to voluntarily convert from aggregate reporting to a new online system where they reported each individual error. Methods A new optional web-based reporting tool was made available to all 393 North Carolina nursing homes to submit error reports for each distinct medication error as they occurred during the year. Results A total of 5823 medication error reports were submitted by 203 sites (52%) using the new system during the reporting year, a median of 18 error reports per site. Of the 5823 error reports, 612 (10.5%) were categorised as serious. Serious errors were more likely to be caused by drugs given to the wrong patient (RR 4.39, CI 3.7 to 5.2), lab-work error (RR 2.40, CI 1.4 to 4.0), wrong product given (RR 2.22, CI 1.8 to 2.8) and medication overdoses (RR 1.49, 1.2 to 1.8). Serious errors were more likely to occur on second shift (RR 1.32, 1.1 to 1.5). Common medications that are involved in the most serious errors include warfarin (RR 2.58, CI 2.09 to 3.18) and insulin (RR 2.35, CI 1.86 to 2.97), and oxycodone combinations (RR 1.48, CI 1.07 to 2.06). Conclusions Data collected from a nursing home medication error system can provide helpful information on serious errors that can be used to focus patient safety efforts to reduce harm. This improved information will be useful in nursing homes for continuous quality improvement efforts.

Medication Errors in Nursing Homes: A State??s Experience Implementing a Reporting System

Objectives: North Carolina legislation enacted in 2003 requires all nursing homes to report medication errors. A statewide mandatory nursing home medication error reporting system for reporting errors annually on an aggregate basis for all 385 licensed nursing homes in North Carolina, exclusive of hospital-based facilities, was implemented. Methods: A Web-based reporting tool was developed for nursing home staff to report retrospective year-end summary data of all medication errors occurring during a nine-month period. A voluntary follow-up survey was used at the end of the data collection period to evaluate the reporting process. Results: North Carolina is the first state to implement mandatory reporting of all medication errors in nursing homes, including near misses and potential errors. One hundred percent of nursing homes submitted a medication error report. A total of 10,920 errors, including near misses, dose omissions and potential errors were reported statewide for the first annual report, which included nine months of experience. Most of errors, 91.1% did not reach nor harm the patient. Twenty-five percent of sites completed a follow-up survey. Reporting was a positive experience for most sites. Conclusions: Mandatory reporting of medication errors by nursing home personnel on an annual basis is feasible on a statewide basis. Data are limited due to the summary nature, and there is significant potential for under-reporting. With education, however, data should improve over time. The reporting requirement encourages nursing homes to consistently record and review medication error incidents and influences patient safety processes.

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

To explore the use of disproportionality analysis of medication error data as a novel method to identify relationships that might not be obvious through traditional analyses. This approach can supplement descriptive data and target quality improvement efforts.