Link to College of Public Health

Patient Safety in Long-Term Care

Complete Bibliography (pdf format)

Click on the topic of your choice. Click again to close.

Falls

Abrahamsen, C. (2002). Revisit patient safetyinitiatives.Nurs Manag 33(6), 47-8.

Becker, D.W., Evans, R.S., Murff, H., Stetson, P.D. etal. (2003). Effectiveness of a multifaceted intervention on falls in nursinghome residents.Journal of the American Geriatric Society, 51(3),306-11.

Burl, J.B., Centola, J., Bonner, A., Burque, C.(2003, Sept - Oct). Hip protector compliance: A 13-month study on factors andcost in long-term care facility.Journal of the American Medical DirectorsAssociation, 4(5), 245-250.

Capezuti, E., Maislin, G., Strumpf, N., Evans, L.K.(2002). Side rail use and bed-related fall outcomes among nursing homeresidents.Journal of the American Geriatric Society, 50(1),90-6.

Cumming, R.G. (2002). Intervention strategies and risk-factor modification for falls prevention: A review of recent intervention studies. Clinics in Geriatric Medicine, 18(2), 175-89.

Edelberg, H.K. (2001). Falls and function: How to prevent falls and injuries in patients with impaired mobility. Geriatrics, 56(3), 41-5,9.

Evans, D., Fitzgerald, M. (2002). Reasons for physically restraining patients and residents: A systematic review and content analysis. Int Journal of Nurs Stud, 39(7), 735-43.

Granek, E., Baker, S.P., Abbey, H. (1987). Medication and diagnoses in relation to falls in long-term care facility. Journal of the American Geriatric Society, 35, 503-11.

Guide to bed safety: Bed rails in hospitals, nursing homes, and home health (pdf format) (2000). Washington, D.C.: Food and Drug Administration.

Hagerty, D. (2002, September). Safety program: Sunset for sundowning. Nursing Homes Long-Term Care Management, 51(9), 19-20.

Hill-Westmoreland, E.E., Soeken, K., Spellbring, A.M. (2002, Jan-Feb). Meta-analysis of fall prevention programs for the elderly: How effective are they? Nursing Research, 51(1), 1-8.

Jenson, J., Lundin-Olsson, L., Nyberg, L., Gustafson, Y. (2002). Fall and injury prevention in older people living in residential care facilities: A cluster randomized trial. Annals of Internal Medicine, 136(10), 733-41.

Joint Commission on Accreditation of Healthcare Organizations (2000). Fatal falls: Lessons for the future. Sentinel Event Alert (series online). 14:3.

Kallen, K., Lundin-Olsson, L., Nyberg, L., Gustafson, Y. (2002). Predisposing and precipitating factors for falls among older people in residential care. Public Health, 116(5), 263-71.

Kanten, D. et al. (1993). Falls: An examination of three reporting methods in nursing homes. Journal of the American Geriatrics Society, 41, 662.

Leipzig, R.M. Cumming, R.G., Tinettie, M.E. (1999). Drugs and falls in older people: A systematic review and metanalysis: I. Psychotropic drugs. Journal of the American Geriatric Society, 47, 30-9.

Leipzig, R.M. Cumming, R.G., Tinettie, M.E. (1999). Drugs and falls in older people: A systematic review and metanalysis: II. Cardiac and analgesic drugs. Journal of the American Geriatric Society, 47, 40-50.

McCurdo, M.E. (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49, 664.

Moreland, J.D., Richardson, J.A., Goldsmith, C.H., Clase, C.M. (2004, July). Muscle weakness and falls in older adults: A systematic review and meta-analysis. Journal of the American Geriatrics Society, 52(7), 1121-9.

Palmer, M. (1996, September). Now it's safety first. Nursing Homes Long Term Care Management, 45(8), 29-32+.

Robertson, M.C., Campbell, A.J., Gardner, M.M., Devlin, N. (2002, May). Preventing injuries in older people by preventing falls: A meta-analysis of individual-level data. Journal of the American Geriatrics Society, 50(5), 905-11.

Rubenstein, L.Z., Josephson, K.R., and Robbins, A.S. (1994). Falls in the nursing home. Annals of Internal Medicine, 121, 442-51.

Ryan, A. (2003).Rights, risks and autonomy: A new interpretation of falls in nursing homes.Qual Saf Health Care, 12,166-7.

Tideisksaar, R.(1998).Falls in older persons: Prevention and Management.Baltimore, MD:Health Professions Press.

Thapa, P.B.,Gideon, P., Cost, T.W. et al. (1998). Antidepressants and the risk of fallsamong nursing home residents.New England Journal of Medicine, 339,875-82.

Ungar, Y. (2001, August). Catch a falling star. Nursing Homes Long-Term Care Management, 50(8), 26+.

Weiner, D.K., Hanlon, J.T., Studenski, S.A. (1998). Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly. Gerontology, 44, 217-21.

Wandering

Abrahamsen, C. (2002). Revisit patient safetyinitiatives.Nurs Manag 33(6), 47-8.

Clark, Thomas (2003, February).Feeling safe.Contemporary and long-term care 26(2), 20-24.

Davis, C. (1996, February). Making the most of wander control technology. Nursing Homes Long Term Care Management, 45(2), 34-5.

Dutton, E. L. (2002, December). Safety and sound.Contemporary Long Term Care, 25(12), 20-1.

Hagerty, D. (2002, September). Safety program: Sunset for sundowning. Nursing Homes Long-Term Care Management, 51(9), 19-20.

Hance,B. (2001, June). Alzheimer'scare puts safety to the test.Assisted Living Today, 8(5),30-3.

Levin, S.M., Mulligan, J.F. (2000, Fall). Litigating nursing home wandering cases. Elder's Advisor, 2, 9-10.

Maher, L. (2001, July). Little Magic works wonders. Contemporary Long Term Care, 24(7), 13.

Peatfield, J.G., Futrell, M., Cox, C.L. (2002, April). Wandering: An integrative review. Journal of Gerontological Nursing, 27(4), 45-50.

Wilber,K., Machemer, J. (1999, Fall-Winter). Balancing the competing values of freedom and safety in long-term dementia care: The Secured Perimeter Program. Journal of Ethics, Law, and Aging, 5(2), 121-30.

Medication Errors

American Society of Consultant Pharmacists. Guidelines on preventing medication errors in pharmacies and long-term care facilities through reporting and evaluation.

American's Senior Care Pharmacist. (2000). Medicationrelated problems in older adults.

Barker,K.N., Flynn,E.A., Pepper, G.Aet al.(2002). Medication errors observed in 36 health care facilities.Archives ofInternal Medicine, 162, 1897-903.

Beers, M.H., Ouslander, J.G., Rollingher, I. et al.(1991). Explicit criteria for determining inappropriate medication use innursing home residents.Archives of Internal Medicine, 151,1825-32.

Beers, M.H. (1997). Explicit criteria for determiningpotentially inappropriate medication use by the elder: An update.Archives ofInternal Medicine, 157, 1531-6.

Beers, M.H. Ouslander, J.G., Fingold, S.F.etal. (1992). Inappropriate medication prescribing in skilled nursingfacilities.Annals of Internal Medicine, 117,684-9.

Burl, J.B., Centola, J., Bonner, A., Burque, C.(2003, Sept - Oct). Hip protector compliance: A 13-month study on factors andcost in long-term care facility.Journal of the American Medical DirectorsAssociation, 4(5), 245-250.

Cooper, J.W. (1996). Probable adverse drug reactions in a rural geriatric nursing home population: A four-year study. Journal of the American Geriatric Society, 44, 194-7.

Dhall, J., Larrat, E.P., Lapane, K.L. (2001). Use of potentially inappropriate drugs in nursing homes. Pharmacotherapy, 22(1), 88-96.

Dhalla, I.A., Anderson, G.M, Mamdani, M.M., Bronskill, S.E. et al. (2002). Inappropriate prescribing before and after nursing home admission. Journal of the American Geriatric Society, 20(6), 995-1000.

Field, T.S., Gurwitz, J.H., Avorn, J. et al. (2001). Risk factors for adverse drug events among nursing home residents. Archives of Internal Medicine, 161, 1629-34.

Gray, S.L., Hedrick, S.C., Rhinard, E.E. et al. (2003). Potentially inappropriate medication use in community residential care facilities. Annals of Pharmacotherapy, 37(7/8), 988-93.

Gurwitz, J.H., Rochon, P. (2002). Improving the quality of medication use in the elderly: A not-so-simple prescription. Archives of Internal Medicine, 162, 1670-2.

Gurwitz, J.H., Field, T.S., Avorn, J. et al. (2000). Incidence and preventability of adverse drug events in nursing homes. American Journal of Medicine, 109, 87-94.

Harjivan, C., Lyles, A. (2002).Improved medication use in long-term care: Building on the consultantpharmacist's drug regimen review.American Journal of Managed Care, 8(4),318-26.

Kelly, W.N. (2002). First do no harm: Reducing medication errors in long-term care. Annals of Long-Term Care, 10, 49-56.

Leape, L.L., Bates, D.W., Cullen, D.J. et al. (1995). Systems analysis of adverse drug events. JAMA, 274(1), 35-43.

Leipzig, R.M. Cumming, R.G., Tinettie, M.E. (1999). Drugs and falls in older people: A systematic review and metanalysis: I. Psychotropic drugs. Journal of the American Geriatric Society, 47, 30-9.

Leipzig, R.M. Cumming, R.G., Tinettie, M.E. (1999). Drugs and falls in older people: A systematic review and metanalysis: II. Cardiac and analgesic drugs. Journal of the American Geriatric Society, 47, 40-50.

Lesser, G.T. (2002). Underestimation of adverse drug events in nursing home residents. Archives of Internal Medicine, 162, 609.

Monette, J., Gurwitz, J.H., Avorn, J. (1995). Epidemiology of adverse drug events in the nursing home setting. Drugs Aging, 7, 203-11.

Morimoto, T. Gandhi, T.K., Seger, A.C., Hsieh, T.C., Bates, D.W. (2004). Adverse drug events and medication errors : Detection and classification methods. Qual Saf Health Care, 13(4), 306-14.

Reese, D. (1997, Nov.). One pill too many. Contemporary Long-Term Care, 20, 65.

Ruths, S., Straand, J., Nygaard,H.A. (2003). Multidisciplinary medication review in nursing home residents: Whatare the most significant drug-related problems? The Bergen District Nursing Home(BEDNURS) study.Qual Saf Health Care, 12, 176-80.

Ryan, A. (2003). Rights, risks andautonomy: A new interpretation of falls in nursing homes.Qual Saf HealthCare, 12, 166-7.

Thapa, P.B., Gideon, P., Cost, T.W.et al. (1998). Antidepressants and the risk of falls among nursing homeresidents.New England Journal of Medicine, 339,875-82.

Uribe,C.L., Schweikhart, S.B., Pathak, D.S., Dow, M., & Marsh, G.B. (2002). Perceived barriers to medical-error reporting: An exploratory investigation. Journal of Healthcare Management, 47(4), 263-79.

Weiner, D.K., Hanlon, J.T., Studenski, S.A. (1998). Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly. Gerontology, 44, 217-21.

Williams, B., Betley, C. (1995). Inappropriate use of nonpsychotropic medications in nursing homes. Journal of the American Geriatric Society, 43, 513-9.

Organizational Environment

Aspden,P., Corrigan, J., Wolcott, J., & Erickson,S. (2004) Patient safety: Achieving a new standard of care. Washington DC: National Academies Press.

Bakken, S., Cimino, J.J., & Hripcsak, G. (2004). Promoting patient safety and enabling evidenced-based practice through informatics. Med Care, 42(2 Suppl), ll49-56.

Battles, J.B. & Lilford, R.J. (2003). Organizing patient safety research to identify risks and hazards. Qual Saf Health Care, 12, Suppl2, 112-17.

Beyea, S.C. (2004). Creating a just safety culture. Aorn Journal, 79(20), 412-4.

Clark, Thomas (2003, February).Feeling safe.Contemporary and long-term care 26(2), 20-24.

Collopy, B.I. (1995, August). Safeand unsound.Contemporary Long Term Care, 18(8),44-8.

Goodman, G.R. (2004). How cannurses help patients work more effectively with nurses to improve the safety ofpatient care?Nursing Economist, 22(2), 100-2.

Gurwitz, J.H., Sanchez-Cross, M.T., Eckler, M.A., Matullis, J. (1994). Epidemiology of adverse and unexpected events in the long-term care setting. Journal of the American Geriatric Society, 42, 33-8.

Hance,B. (2001, June). Alzheimer'scare puts safety to the test.Assisted Living Today, 8(5),30-3.

Hemman, E.A. Creating healthcare cultures of patient safety. Journal of Nursing Administration, 32(7-8), 419-27.

Johnson, K. (2004). Keeping patients safe: An analysis of organizational culture and caregiver training. Journal of Healthcare Management, 49(3), 171-8.

Kapp, M.B. (2003) At least mom will be safe there: The role of resident safety in nursing home quality. Qual Saf Health Care 12(3), 201-4.

Kapp, M.B. (1997). Errors in health care: Let's not forget about long-term-care settings. Journal of Ethics, Law & Aging, 3, 75.

Kapp, M.B. (2003). Resident safety and medical errors in nursing homes: Reporting and disclosure in a culture of mutual distrust. Journal of Legal Medicine, 24(1), 51-76.

Kohn, L.T., Corrigan, J.M., Donaldson, M.S. (Eds). (1999). To err is human: Building a safer health system. Washington D.C.: National Academy Press.

Liang, B.A. (2000). Patient safety through reducing medical error: A paradigm of cooperation between patient, physician, and attorney. Southern Illinois University Law Journal, 24, 541, 542-3.

Liang, B.A. (2001). The adverse event of unaddressed medical error: Identifying and filling the holes in the health-care and legal systems. Journal of Law, Medicine & Ethics, 29, 346.

Lynn, J., Goldstein, N.E. (2003, May 20). Advance care planning for fatal chronic illness: Avoiding commonplace errors and unwarranted suffering. Annals of Internal Medicine, 138(10), 812-8.

Maher, L. (2001, Jul). Little Magic works wonders. Contemporary Long Term Care, 24(7), 13.

Marshall, B.K. (2001). Medical mistakes and older patients: Admitting errors and improving care. Journal of the American Geriatric Society, 49, 1321.

Nieva, V.F., Sorra, J. (2003). Safety culture assessment: A tool for improving patient safety in healthcare organizations. Qual Saf Health Care, 12 Suppl 2:ii, 17-23.

Palmer, M. (1996, September). Now it's safety first. Nursing Homes Long Term Care Management, 45(8), 29-32+.

Resident safety and health careerror reduction standards. (2002, April).Jt Comm Perspec, 22(4),7-13.

Roadmap for safety: Nationalquality forum officially releases 30 safe practices for better healthcare (2003,July).The Quality Letter for Healthcare Leaders, 15(7),12-4.

Ruchlin,H.S., Dubbs, N.L., Callahan, M.A. (2004) The role of leadership in instilling a culture of safety:Lessons from the literature.Journal of Healthcare Management, 49(1),47-58; discussion 58-9.

Spath, P.L. (Ed.). (2000). Errorreduction in health care: A systems approach to improving patient safety. SanFrancisco: Jossey-Bass Publishers.

Swift, E.K., Koepke, C.P., Ferrer,J.A., Miranda, D. (2001, Fall). Preventing medical errors: Communicating a rolefor Medicare.Health Care Financing Review, 23(1),77-85.

Thompson, James J. (2003,February). Safety: A key ingredient in the recipe for success.Nursing Homesand Long Term Care Management, 52(2), 22.

Uribe,C.L., Schweikhart, S.B., Pathak, D.S., Dow, M., & Marsh, G.B. (2002). Perceived barriers to medical-error reporting: An exploratory investigation. Journal of Healthcare Management, 47(4), 263-79.

Wears, R.L. Wu, A.W. (2002). Dealing with failure: The aftermath of errors and adverse events. Annals of Emergency Medicine, 39, 344-5.

Wilber,K., Machemer, J. (1999, Fall-Winter). Balancing the competing values of freedom and safety in long-term dementia care: The Secured Perimeter Program. Journal of Ethics, Law, and Aging, 5(2), 121-30.

Wolfe, E.J. (July-August, 2004). Promoting patient safety through facility design. Healthcare Executive, 18(4), 16-20.

Legal Climate

Collopy, B.I. (1995, August). Safe and unsound. Contemporary Long Term Care,18(8), 44-8.

Kapp, M.B. (2003). Resident safety and medical errors in nursing homes: Reporting and disclosure in a culture of mutual distrust. Journal of Legal Medicine, 24(1), 51-76.

Laing, B.A. (1999). Error in medicine: Legal impediments to U.S. reform. Journal of Health Policy, Policy & Law, 24, 27.

Liang, B.A. (2001). The adverse event of unaddressed medical error: Identifying and filling the holes in the health-care and legal systems. Journal of Law, Medicine & Ethics, 29, 346.

Levin, S.M., Mulligan, J.F. (2000, Fall). Litigating nursing home wandering cases. Elder's Advisor, 2, 9-10.

Van Grunsven, P.R. (1996). Criminal prosecution of health care providers for clinical mistakes and fatal errors: Is "bad medicine" a crime? J Health 29(2), 107-20.

Disclosure

Baylis, F. (1997). Errors in medicine: Nurturing truthfulness. Journal of Clinical Ethics, 8, 336.

Cohen, J.R. (2000). Apology and organizations: Exploring an example from medical practice. Fordham Urb Law Journal, 27, 1447-82.

Greely, H.T. (1999). Do physicians have a duty to disclose mistakes? Western Journal of Medicine, 171, 82-3.

Kapp, M.B. (2001, Oct.). Medical mistakes and older patients: Admitting errors and improving care. Journal of the American Geriatrics Society, 49(10), 1361-5.

Kapp, M.B. (2003). Resident safety and medical errors in nursing homes: Reporting and disclosure in a culture of mutual distrust. Journal of Legal Medicine, 24(1), 51-76.

Kosner, F. Berger, J.T., Kark, P. et al. (2000). Disclosure and prevention of medical errors. Archives of Internal Medicine, 160, 2089-92.

Kraman, S.S., Hamm, G. (1999). Risk management: Extreme honesty may be the best policy. Annals of Internal Medicine, 131, 963-7.

Liang, B.A. (2000). Patient safety through reducing medical error: A paradigm of cooperation between patient, physician, and attorney. Southern Illinois University Law Journal, 24, 541, 542-3.

Marshall, B.K., Markert, R. (1990). Legal risk management programs in nursing homes: Who has them and do they work? Hospital & Health Services, 35, 603-4.

Marshall, B.K. (2001). Medical mistakes and older patients: Admitting errors and improving care. Journal of the American Geriatric Society, 49, 1321.

Swift, E.K., Koepke, C.P., Ferrer, J.A., Miranda, D. (2001, Fall). Preventing medical errors: Communicating a role for Medicare. Health Care Financing Review, 23(1), 77-85.

Wu, A.W. (1999). Handling hospital errors: Is disclosure the best defense? Annals of Internal Medicine, 131, 970-2.

Wu, A.W. et al. (1997). To tell the truth: Ethical and practical issue in disclosing medical mistakes to patients. General Internal Medicine, 12, 770.

Literature Reviews, Lists, Bibliographies, and Websites

Agency for Healthcare Research and Quality (2000, April). Reducing errors in health care: Translating research into practice. AHRQ Publication No. 00-PO58, Rockville MD.

America's Senior Care Pharmacists. (2000).Medication related problems in older adults.

Cumming, R.G. (2002). Intervention strategies and risk-factor modification for falls prevention: A review of recent intervention studies. Clinics in Geriatric Medicine, 18(2), 175-89.

Lassetter, J.H., & Warnick, M.L. (2003). Medical errors, drug-related problems, and medication errors: A literature review on quality of care and cost issues. Journal of Nursing Care Quality, 18(3), 175-81.