Fostering Activation Among Latino Parents of Children With Mental Health Needs: An RCT.

OBJECTIVE: Latino families raising children with mental health and other special health care needs report greater dissatisfaction with care compared with other families. Activation is a promising strategy to eliminate disparities. This study examined the comparative effectiveness of MePrEPA, an activation intervention for Latino parents whose children receive mental health services. METHODS: A randomized controlled trial (N=172) was conducted in a Spanish-language mental health clinic to assess the effectiveness of MePrEPA, a four-week group psychoeducational intervention to enhance parent activation among Latino parents, compared with a parent-support control group. Inclusion criteria were raising a child who receives services for mental health needs and ability to attend weekly sessions. Outcomes were parent activation, education activation, quality of school interaction, and parent mental health. Effectiveness of the intervention was tested with a difference-in-difference approach estimating linear mixed models. Heterogeneity of treatment effect was examined. RESULTS: MePrEPA enhanced parent activation (ß=5.98, 95% confidence interval [CI]=1.42-10.53), education activation (ß=7.98, CI=3.01-12.94), and quality of school interaction (ß=1.83, CI=.14-3.52) to a greater degree than did a parent-support control group. The intervention's impact on parent activation and education outcomes was greater for participants whose children were covered by Medicaid and were novices to therapy and those with low activation at baseline. No statistically significant effects were observed in parent mental health. CONCLUSIONS: Activation among Latino parents was improved with MePrEPA, which can be readily incorporated in current practices by mental health clinics. Future work should replicate findings in a large number of sites, adding behavioral measures and distal impacts while examining MePrEPA's effects across settings and populations.

The business case for pediatric asthma quality improvement in low-income populations: examining a provider-based pay-for-reporting intervention.

OBJECTIVE: To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State. DESIGN: Practice-level, randomized prospective evaluation. SETTING: Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan). PARTICIPANTS: Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices). INTERVENTION: For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. After each chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care. MAIN OUTCOME MEASURES: Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis). RESULTS: The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization for children in treatment relative to control practices. CONCLUSIONS: A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years.

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.

Appropriate and safe use of medications is an important aspect of quality of care in nursing home patients. Because of their complex medication use process, anticoagulants are prone to medication errors in the frail elderly. Therefore, we designed this study to characterize anticoagulant medication errors and to evaluate their association with patient harm using individual medication error incidents reported by all North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Characteristics, causes, and specific outcomes of harmful anticoagulant medication errors were reported as frequencies and proportions and compared between anticoagulant errors and other medication errors using chi-square tests. A multivariate logistic regression model explored the relationship between anticoagulant medication errors and patient harm, controlling for patient- and error-related factors.

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.

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.

Online medication error graphic reports: a pilot in North Carolina nursing homes.

OBJECTIVES: Since 2003, North Carolina nursing homes have been required by state law to report all medication errors, but the nursing homes have not had usable and timely access to their own error data. We created and pilot tested a new online graphic reporting feature to give homes practical and timely reports on their own reported errors for use in improving medication processes. METHODS: The new graphic reports feature was added to the existing online reporting system and provides immediate access to a set of tables and graphs on all submitted errors. Fifteen nursing homes were recruited to participate in a pilot test of the graphic reports. Key informant interviews were conducted to gather in-depth qualitative information on the use of the reports. RESULTS: The reports were used primarily for providing information to members of the quality assurance committee and for staff training. Sites had very few technical problems accessing or printing the reports and were able to view them on existing computer systems. Sites with significant numbers of submitted errors in the system reported greater usefulness of the graphics than sites with few errors. Staff turnover at the director of nursing position was the most common reason for low participation at some sites. CONCLUSIONS: The online graphic reports are a positive, user-friendly next step in providing information to the nursing homes to use in improving patient safety. The information is deemed by the users to be the right content, professional in appearance, and accessible to the nursing home.

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

PURPOSE: 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. METHODS: Data came from the Medication Error Quality Initiative (MEQI) individual event reporting system. Participants were North Carolina nursing homes who submitted incident reports to the Web-based MEQI data repository during the 2006 and 2007 reporting years. Data from 206 nursing homes were summarized descriptively and then disproportionality analysis was applied. Associations between medication type and possible causes at the state level were explored. A single nursing home was selected to illustrate how the method might inform quality improvement at the facility level. Disproportionality analysis of drug errors in this home was compared with benchmarking. RESULTS: Statewide, 59 drug-cause pairs met the disproportionality signal and 11 occurred in 10 or more reports. Among these, warfarin was co-reported with communication errors; esomeprazole, risperidone, and nitrofurantoin were disproportionately associated with transcription error; and oxycodone and morphine were disproportionately reported with name confusion. Facility-level analyses illustrate how descriptive frequencies and disproportionality analysis are complementary, but also identify different safety targets. CONCLUSIONS: Exploratory analysis tools can help identify medication error types that occur at disproportionate rates. Candidate associations might be used to target patient safety work, although further evaluation is needed to determine the value of this information.

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 Carolina's 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.

Types of medication errors in North Carolina nursing homes: a target for quality improvement.

BACKGROUND: Medication errors are an important problem in nursing homes, but little is known about the types of medications involved in errors in this setting. Gaining a better understanding of the types of medications commonly involved in medication errors in nursing homes would be an important step toward quality improvement. OBJECTIVES: This study sought to describe the types of medication errors most frequently reported to a statewide repository by North Carolina nursing homes. We also examined whether nursing homes reporting an error involving a drug on the updated Beers list of medications considered potentially inappropriate for use in the elderly were likely to report a greater number of medication errors or more harmful medication errors compared with nursing homes that did not report such an error. METHODS: Medication errors were defined as preventable events that had the potential to cause/lead to or actually caused/led to inappropriate medication use or patient harm. We analyzed summary reports of medication errors submitted to the State of North Carolina by licensed nursing homes for the 9-month period from January 1, 2004, to September 30, 2004, using a Web-based reporting system. Drugs commonly involved in medication errors were summarized for all nursing homes in the state. Errors involving medications on the updated Beers list also were identified. Nursing homes were profiled and compared according to the type of medication error and whether the error reached the patient and/or caused harm. RESULTS: Among the 384 licensed nursing homes included in our analysis, 9272 medication errors were reported. The specific medication involved was documented for 5986 of these errors. The medications most commonly involved in an error were lorazepam (457 errors [8%]), warfarin (349 [6%]), insulin (332 [6%]), hydrocodone and hydrocodone combinations (233 [4%]), furosemide (173 [3%]), and the fentanyl patch (150 [3%]). The medication errors disproportionately included central nervous system agents (16%) and analgesics (11%). Medications considered potentially inappropriate in the elderly were frequently involved in the reported errors (10% of all reported errors), with the greatest number of such errors associated with lorazepam (457 [8%]), alprazolam (130 [2%]), and digoxin (74 [1%]). Nursing homes reporting potentially inappropriate drugs among their 10 most common medication errors also reported a significantly greater mean number of errors compared with nursing homes that did not report such errors (26.9 vs 17.6, respectively; P < 0.001), as well as a significantly greater number of errors that reached the patient (6148 vs 1393; P < 0.001). CONCLUSION: Based on the experience in North Carolina, quality improvement efforts in nursing homes should focus on the medications commonly involved in errors and should continue to discourage or closely monitor the use of medications considered potentially inappropriate in the elderly.