0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review Article |

Preventable Medical Injuries in Older Patients FREE

Jeffrey M. Rothschild, MD, MPH; David W. Bates, MD, MSc; Lucian L. Leape, MD
[+] Author Affiliations

From the Division of General Medicine, Department of Medicine, Brigham and Women's Hospital (Drs Rothschild and Bates), Harvard Medical School (Drs Rothschild and Bates), and the Harvard School of Public Health (Dr Leape), Boston, Mass.


Arch Intern Med. 2000;160(18):2717-2728. doi:10.1001/archinte.160.18.2717.
Text Size: A A A
Published online

Injuries associated with hospitalization are more common in older (≥65 years) than in younger patients (<65 years), and they may be more severe and more often preventable. The increasing age of the population magnifies the importance of this problem. In this review, we first consider medical injuries in general and then review the literature for 6 categories: adverse drug events, falls, nosocomial infections, pressure sores, delirium, and surgical and perioperative complications. For each of these categories, older patients appear to be at higher risk, ranging from a 2.2-fold increase for perioperative complications to a 10-fold increase for falling, based on Harvard Medical Practice Study rates. The main cause of these increased risks appears to be the diminished physiological reserve of elderly patients; however, age alone is a less important predictor of adverse events than comorbidities and functional status. Furthermore, many of these complications appear to be preventable, although the proportion preventable varies by type of complication. While some prevention strategies are specifically beneficial in older patients, many apply to all age groups. Geriatric care units and consultation systems have improved outcomes in some instances, although the data are mixed. The success of intervention varies by type of complications. For medications, various interventions have been successful, and fall prevention programs have been demonstrated to be effective in the nursing home and home.

As the data about the frequency and consequences of iatrogenic injury have accumulated,1 concern about injury in older patients (≥65 years) has increased. Older patients are at special risk, have special problems, and may require special measures to achieve acceptable levels of safety in health care. Demographic trends indicate that age-related health issues will be of increasing importance in all health care settings.

The population of Americans older than 65 years reached 34 million in 1997 and is expected to double by 2030.2 In 1995, more than 40% of hospital admissions were in this age group. Because of their longer average length of stay (mean, 7.1 vs 5.4 days), hospital occupancy attributed to older patients is even greater: 49%.3 Nearly 2 million Americans live in nursing homes, and the figure is expected to reach 5 million by 2030.4 In recent years, the average nursing home resident has become older, sicker, and more functionally dependent.5 Shortage of nursing home beds, and increasing utilization constraints for hospitalized patients, has forced many patients who previously would have been institutionalized to receive care in the community.

Outpatient use of medical services also increases with age. Reasons for these trends include advances in medical technology, increased public awareness and preferences, growing populations of chronically ill survivors, concerns of the increased risks of hospitalization, and the increasing costs of hospital care.6 In 1995, persons older than 65 years averaged 11 physician contacts annually compared with 5 for younger patients. In 1993, 3 million Medicare recipients received 160 million home health care visits.7 In addition, the use of high-technology care in the home is growing exponentially.8

Unintentional medical injuries are a serious public health problem. Data from hospital and nursing home studies911 suggest that elderly patients are at particular risk. Less evidence is available concerning the extent and nature of medical injuries in the outpatient and home health settings, although it seems likely that older patients are at increased risk in these settings as well. Most studies targeting medical injuries in the older patients are recent, but several are from the early 1980s and may not reflect current conditions.

The Harvard Medical Practice Study12 defined an adverse event as an unintended injury caused by medical management that resulted in measurable disability. Such events occurred in nearly 4% of hospitalized patients. More than two thirds of these iatrogenic injuries were due to errors and were, therefore, potentially preventable.13 Adverse events were more common in patients aged 65 years and older, even after adjusting for comorbidities (Table 1).

Table Graphic Jump LocationTable 1. Harvard Medical Practice Study: Injuries in Older Patients*

Other studies suggest that the Harvard Medical Practice Study may have underestimated the frequency of iatrogenic injury. For example, in one of the earliest prospective studies of older patients, a 1962 prospective study14 of 500 consecutive admissions of elderly indigent patients admitted to a single medical service, it was found that 29% had complications as a result of hospitalization. In another hospital study,15 the complication rate for the younger group (mean age, 50.3 years) was 29% compared with 45% for the older group (mean age, 73.1 years).

Among nursing home patients, Gurwitz et al16 found 3890 reported events in a 1-year study in a 700-bed long-term care facility. The most common events were falls (n = 2032), non–fall-related injuries (n = 1631), and adverse drug events (ADEs) (n = 180). Long-term care facilities have been required by the Omnibus Budget Reconciliation Act of 1987 to record more than 300 diagnostic, demographic, clinical, and treatment variables using the Minimum Data Set and the Resident Assessment Protocols.17 These quality indicators are organized into care domains, such as accidents, nutrition, skin care, infection control, and others.1820

Recently, the Center for Health Systems Research and Analysis at the University of Wisconsin–Madison has developed a modified Minimum Data Set (version 2.0) that it has used to record the care of nursing home residents from several regions.21 Data from this database for 4 midwestern states are shown in Table 2 for selected events from 1992 to 1995; extrapolated nationwide estimates are also given. With the exception of restraint use (38% decline), there were few patterns of improvement during the 4-year study cycle.

Table Graphic Jump LocationTable 2. Center for Health Systems Research and Analysis Multiple Data Set 2.0: Mean Prevalence Rates for Selected Quality Indicators
Adverse Drug Events

Adverse drug events are the most common type of adverse event in hospitalized patients, including patients aged 65 years or older.22 An ADE has been defined as an injury resulting from the medical use of a drug.23 Adverse drug events include preventable ADEs (those due to errors) and nonpreventable ADEs, also called adverse drug reactions.16,2428 In one large study29 of older patients admitted to 41 clinical centers, 5.8% were identified as having an ADE during their hospital course. However, Gray et al30 found a 14.8% incidence of ADEs among hospitalized older patients (mean age, 78.2 years), considerably greater than the ADE rates of 2.0% to 6.5% in larger studies31,32 that were not restricted to elderly patients.

In addition to these ADEs that occur during hospitalization, these events are also an important cause of admission to the hospital in older patients. In 1969, Hurwitz33 observed that ADEs contributed to the need for hospitalization in 15% of patients aged 60 years or older, which was 2.5 times the rate in younger patients. In a study of 2000 geriatric admissions, Williamson and Chopin34 found that ADEs were responsible for 10.5% of the admissions.

Adverse drug events are also common in nursing homes. In one prospective study35 over a 4-year period, 217 (65.4%) of 332 nursing home residents had 444 ADEs. Also, an 18-month retrospective study36 of veterans admitted to a nursing home found that 32% had ADEs.

The outpatient setting poses difficult challenges for researchers investigating ADEs in elderly patients. Most outpatient studies have relied on patient self-reporting. In one study37 of mostly older patients interviewed by telephone, 30% described at least one medication causing undesirable symptoms. In contrast, in a 1-year study38 of outpatients in which ADEs were detected by medical record review, a 10% incidence of ADEs was found. Prescription of multiple drugs has also been associated with a higher frequency of ADEs. Among 167 elderly veterans taking a minimum of 5 medications each (mean, 8 drugs per patient), 35% reported having had at least one ADE in the prior year. A quarter of those ADEs resulted in an emergency department visit or hospitalization.26

Most ADEs are unpredictable and unpreventable, at least given the present state of knowledge. However, among hospital patients in one study,31 28% were judged preventable; this study did not consider inappropriate prescribing, so the total figure may be higher. In the outpatient setting, studies3941 have found that 7.5% to 23.5% of patients receive inappropriate or contraindicated drugs.

Falls and Restraints

Falls are a major source of morbidity and mortality in older patients (Table 3).4751 In 1985, falls resulted in more than 2 million injuries, 369,000 hospital admissions, and nearly 9000 deaths. In a study52 of hospitalized patients of all age groups, the incidence of falls for elderly patients was 1.9%. In another inpatient study23 not limited to older patients, the estimated incidence of falls and injurious falls was 0.66% and 0.04%, respectively. Like many other studies of falls, this one was limited by its dependence on incident reports. Among nursing home patients, approximately half fall each year, and 9% sustain serious injury.53 The 1-year incidence of falls among elderly patients living in the community is 32%, with resultant serious injuries in 24% of those who fall.54 Recent estimates for fall-related hip fractures are 250,000 annually, a figure that is expected to double by the year 2040.55

Table Graphic Jump LocationTable 3. Falls, Pressure Sores, and Inpatient Delirium*

Patients at risk for falling pose difficult management issues. Restraint use (physical and chemical) has become controversial in recent years.56 Furthermore, the effectiveness of physical restraint in reducing falls or preventing injury is questionable.5658 In fact, restraints in hospitalized patients have been associated with increased mortality rates, longer lengths of stays, pressure sore development, increased incidence of nosocomial infections, and emotional distress.48,57,59

Nosocomial Infections

Hospitalized older patients appear to be particularly susceptible to nosocomial infections.60,61 The incidence of hospital-acquired nosocomial infections in older patients ranges from 5.9 to 16.9 per 1000 hospital days.62 A retrospective review63 of 1200 nosocomial infections found the risk in the 70 to 79 years age group to be 10 times that for the 40 to 49 years age group. Nosocomial infections in the nursing home setting are also a major problem. In a study64 of 4259 residents in 53 nursing homes, the 1-day prevalence rate for newly acquired nosocomial infections was 4.4%. One kind of nosocomial infection, pneumonia, accounts for 29% of hospital admissions of patients from nursing homes.65,66

Pressure Sores

Frail individuals are especially vulnerable to pressure sores (Table 3).6769 Approximately 5% of hospitalized patients acquire pressure sores during their stay, resulting in 1.7 million hospital-related cases per year.4 Among high-risk hospitalized older patients, the incidence ranges up to 30%.70 In nursing homes, a 51-site study71 of nearly 20,000 residents revealed that 11% already had a pressure sore on admission, and for the remainder, the subsequent 1-year incidence was 13%. Another nursing home study72 found that among newly admitted high-risk patients, the incidence for acquiring a new pressure sore within 8 weeks climbs to 74%.

Delirium

Hospital-acquired delirium, especially after surgery, is predominantly a disease of elderly patients, and complicates 2.3 million admissions annually.73,74 Delirium at the time of admission is an independent predictor of poor hospital outcome.74 The prevalence of delirium on admission ranges from 14% to 24% of older patients, and new cases develop during hospitalization in 9% to 31% of older patients (Table 3).67,7478 Postoperative delirium is associated with prolonged length of hospital stay, increased costs, morbidity, and mortality.74

Surgical and Perioperative Complications

In the Harvard Medical Practice Study,22 postoperative complications accounted for half of all adverse events and were nearly twice as frequent among older patients. In a more recent study79 of surgical adverse events in Colorado and Utah, after adjusting for comorbidities, age remained a risk factor for preventable events. Elderly patients account for half of all surgical emergencies and three quarters of operative deaths.10 In a study80 of 613 surgical patients older than 70 years, mortality was significantly higher for emergency operations (21%) compared with elective cases (1.9%).

The greater risk of harm from medical interventions to older patients results from increased exposure to opportunities for medical mistakes and from the likelihood that those mistakes will then lead to actual injury. Factors increasing risk include those associated with the aging process itself ("endogenous factors") and those related to care ("exogenous factors").

Endogenous Factors

Older patients have diminished reserves, especially in cognitive, renal, and hepatic function. Cascade iatrogenesis is especially frequent in elderly patients; it is the serial development of multiple medical complications associated with reduced mechanisms for coping with external stresses.81 An example is a patient with postoperative pain who was oversedated, leading to respiratory failure that required mechanical ventilation, who subsequently developed ventilator-associated pneumonia.

The development of adverse events or disability during hospitalization in older patients is strongly associated with a poorer prognosis following hospital discharge.3 Risk factors predicting postdischarge functional decline include preexisting bedsores, poor scores on the Mini-Mental State Examination, impairment in activities of daily living, and reduced social activity.3,82 The Hospital Outcomes Project for the Elderly found that, following discharge from hospitalization, a third of patients declined in at least one of their activities of daily living. The causes of functional decline include the effects of illness itself, treatment, adverse events, and deconditioning.83 In these patients, subsequent risks of falls, rehospitalization, institutionalization, and dying are substantially increased.3

Exogenous Factors

In addition to an increased rate of complications from usual medical therapy, such as bed rest, older patients have iatrogenic injuries from inappropriate care. For example, congestive heart failure is the most common reason for hospitalization of elderly patients, responsible for more than 500,000 admissions per year.84 In a prospective observational study,84 7% of admissions for congestive heart failure were found to be the result of improper treatment, including fluid overload, procedures, and misuse of drugs. Hospital mortality for this group with congestive heart failure was much greater, 32%, as opposed to 9% in the group without iatrogenic injuries. In a prospective study85 of inpatient renal service consultations for predominantly older patients, the most common causes for acute renal failure were iatrogenic: drugs, errors in perioperative care, dehydration, and contrast dye.

Underdiagnosis and delayed diagnosis of illnesses are more common in elderly patients.10 Factors associated with underdiagnosis include the following: patient-related causes, such as symptom denial, symptom attribution to old age, and patient passivity during physician encounters; systems-related causes, such as inadequate medical access and disincentives from reimbursement inadequacies for time-intensive needs of complex older patients; and physician-related causes.10 Underdiagnosis in older patients appears more likely to occur when a nongeriatric physician cares for the patient. For example, some data suggest that patient assessments by non–geriatric-trained providers may be deficient in diagnosing gait disturbances, metabolic problems, early cancers, the presence of untreated infections, and reversible causes of incontinence and dementia.86

One of the reasons for underdiagnosis of illness in elderly patients is atypical presentation. For example, patients may present with signs and symptoms that are remote from the diseased organ system, masking important diagnostic clues. The "weakest link" construct holds that illness will often present as failure of the most vulnerable organ system. Impairment usually predates the new physiologic challenge. For example, delirium, depression, urinary incontinence, or near syncope are not uncommonly associated with remote insults to other organ systems.83

Adverse Drug Events

While the relation between ADE rates and growing older is strong, it is less clear that age is an independent risk factor beyond the increase in illness associated with growing older. Gurwitz and Avorn87 have suggested that while an association does exist for certain medications, many studies addressing this relation fail to account for the confounding effects of increased coexisting illnesses and multiple drug use. One recent study88 addressing this issue in hospitalized patients found no increased risk after controlling for these factors.83

Falls

Age, female sex, and living alone are all associated with increased rates of falling.89 Environmental factors are more important causes of falling for younger elderly patients, while host-related factors (decreased mobility, visual impairment, dizziness, and neurologic or cardiovascular disease) play a more significant role for the more senior and frail elderly patients.90 Nonenvironmental risk factors most associated with falling in long-term care facilities include a history of falling, the ability to walk, dementia, and drug use, particularly sedative-hypnotics, vasodilators, antidepressants (including newer psychotropics), and diuretics.47,9193

Nosocomial Infections

Nosocomial pneumonia among inpatients occurs twice as often in older patients and is associated with poorer outcomes.9496 Older patients are predisposed to pneumonia because of decreased lung capacity, cough reflex, and immunity. Independent risk factors include poor nutritional status, neuromuscular disease, and witnessed aspiration events.94 Pneumonia and urinary tract infections account for approximately half of nosocomial infections in long-term care facilities.97,98 Risk factors responsible for nosocomial infections include urinary catheterization, fecal and urinary incontinence, recent antibiotic use, intravenous lines, nasogastric tubes, and corticosteroid use.99 Nursing homes are also potentially hazardous for acquiring communicable diseases such as tuberculosis. For individuals aged 65 years or older, tuberculosis rates are 4-fold higher in nursing homes than for elderly persons living at home.100

Pressure Sores

Older patients at greatest risk for pressure sores are bedridden or chair bound. Risk factors include fecal incontinence, long lengths of hospital stay, traumatic injuries, neuromuscular diseases, malnutrition, lymphopenia, decreased body weight, dry skin, and an altered level of consciousness.67,101 Skin breakdown develops in the setting of moisture, friction, shearing forces, and pressure.102 Treatment variables that predispose to pressure ulcer development include type of surface support, nurse staffing ratios, frequency of patient repositioning, and certain medications.70

Delirium

The most common causes for delirium are medications, infections, metabolic derangements, and alcohol or drug withdrawal.75 Predisposing factors include age, comorbid conditions, and preexisting cognitive or functional impairment. External influences include insufficient social support, sleep deprivation, unfamiliar environments, pain, and stimuli reduction. In postoperative patients, there is no clear-cut correlation between the route of anesthesia (general, epidural, or regional) and the incidence of postoperative delirium.103,104 The method of pain management may be less significant than the quality of postoperative analgesia as a determinant of developing delirium.105 Physicians fail to diagnose 30% to 50% of delirious patients.106 Reasons include poor patient-physician communication, misdiagnosis as dementia or depression, overlooking delirium while attending to other diseases, and mistakenly attributing the behavior to normal aging.107

Surgical and Perioperative Complications

Age alone is not an important risk factor for many types of surgery. The oldest patients with few comorbid conditions and nonemergency operations have outcomes comparable to younger age groups.108 Studies109111 from the National Veterans Affairs Surgical Quality Improvement Program database have demonstrated that age, as an independent variable, is less important in predicting postoperative outcome than complexity scores, functional status, emergency nature of cases, or the preoperative anesthesia risk assessment scores. Still, the rate of surgical complications consistently increased with age, with 3 to 4 times as many of the oldest patients having more than one complication (Table 4). Following surgery, iatrogenic injury involving the lungs, kidneys, and cardiovascular system increased several-fold with aging (Table 5). Surgeons' reluctance to perform early elective surgery based on chronological age alone may be a factor that has contributed to increased surgical mortality in older patients.112114 When surgeons delay operating on elderly patients until nonsurgical treatments have failed, the perioperative risk is often increased.115

Table Graphic Jump LocationTable 4. VA National Surgical Quality Improvement Program: Incidence of Selected Risk Factors and Outcomes*
Table Graphic Jump LocationTable 5. VA National Surgical Quality Improvement: Incidence of Selected Postoperative Complications After Major Surgery Among Veterans (Fiscal Year 1998)*

In the Harvard Medical Practice Study,12 two thirds of adverse events in hospitalized patients were judged to be preventable. Efforts to prevent medical errors in elderly patients begin with the same principles used successfully in caring for patients of all ages. Four general strategies with promise for reducing accidental injury in older patients are presented, followed by specific recommendations (Table 6).

Table Graphic Jump LocationTable 6. Error Prevention Strategies for Older Patients (≥65 Years)
Application of Lessons in Error Prevention From Other Industries

Successful programs to reduce adverse events should take advantage of techniques from cognitive science and human factors research, systems theory, institutionalizing safety, and cultural shifts.13 High-reliability organizations (such as aviation) emphasize management of work flow and schedules to prevent fatigue and stress and provide extensive training in teamwork and individual responsibility for safety.

The principles of total quality management, including interdisciplinary approaches, are important for preventing errors in the care of elderly patients.13,31,116120 Leape et al117 have outlined several human factors' concepts for medical error reduction that should be built into the design of all systems: simplify, standardize, stratify (customization of care), improve communication, properly use defaults, carefully automate, use affordances and natural mapping, understand limitations of attention and vigilance, and encourage the reporting of errors in a nonpunitive environment. Safety design characteristics also include improving information access, error proofing (including use of forcing functions), reducing reliance on memory, training, and the use of buffers or redundancy to intercept inevitable errors.13

Reducing Variability in the Treatment of Older Patients

Older patients often benefit greatly from interventions, even though their risk is higher.121 For example, for those with atrial fibrillation, older patients benefit the most from anticoagulation, although their risk of complications is highest.122 Inappropriate care of older patients is associated with underuse, overuse, and misuse of acute care medical services, including procedures.123 Many important therapies, including some with increased risks, are actually more effective in elderly patients because the consequences of the untreated conditions are more severe.124

Role of Geriatric Specialists and Geriatric Care Units

Some data, although not all, suggest that outcomes may be better when geriatric physician and nurse specialists care for older patients compared with routine care. In one study95 of patients with nursing home–acquired pneumonia, those cared for by physicians with a Certificate of Added Qualifications in Geriatrics had a 3-fold greater likelihood of achieving cure than patients whose physicians did not have this certificate. In this study, the geriatric physicians had direct patient responsibility and participated in policy decisions.

Also, in geriatric units in which structural and process-oriented factors have been reorganized and directed toward the needs of older patients, care has improved.125 Clinical trials in a hospital medical unit, which was physically redesigned along with a multidisciplinary approach to elderly care and injury prevention, have demonstrated improved functional outcomes while saving costs.126128 "Acute care for elders units" are team directed and function focused and use nontraditional biopsychosocial models.126 The success of acute care for elders units emphasizes the importance of remodeling processes of care and strategies using specialized teams of providers (physicians, nurse practitioners, and physician assistants) with direct responsibilities in patient care. In models that focus on a team approach, it may be the team rather than the attending physician who has the major impact.

In contrast is the lack of benefit seen with geriatric consultation teams. In a Veteran's Administration study,125 the incidence of hospital-acquired complications (38%) was not reduced by the use of the geriatric team. On analysis, the failure appeared to be due to limiting them to a consultative role. Similarly, other comprehensive geriatric assessment studies129 that did not result in concurrent institutional reengineering have had disappointing results.

Risk Profiling and Discharge Planning

Assessing the risk profile of older patients at the time of admission can identify patients at risk for functional decline after hospitalization. The most important independent predictors are advanced age, reduced preadmission independent function as measured by activities of daily living, and cognitive impairment.3 Follow-up patient assessments during the hospital stay are also important in reducing medical complications in patients following transfer or discharge from the hospital to home. In particular, ensuring physiologic stability on discharge from hospitalization improves outcome. Naylor et al130,131 have demonstrated the short-term effectiveness of comprehensive discharge planning for hospitalized elderly patients and the value of intensive follow-up of patients at risk for poor outcomes.

Adverse Drug Events

Reducing ADE rates in older patients will require expanded participation of physicians and other health care professionals, hospital administrators, and the information technology sector to redesign the medication systems in most hospitals. These efforts should also include the following methods.

New Information Technology

Information science solutions to the ADE problem have been successively implemented in several academic centers and are expected to soon gain widespread acceptance.24 Computerized physician order entry with decision support reduced the incidence of serious medication errors by 55% in one study.132 Outpatient pharmacotherapy in elderly patients can be improved with on-line drug utilization review interventions.133 Potentially inappropriate geriatric prescribing was changed in 24% of pharmacy orders after computer-generated alerts.134

Increasing Physician Prescribing Knowledge

Beers135 led a panel of nationally recognized experts who developed explicit criteria of inappropriate drug use in elderly patients. His group outlined 2 classes of drugs that are frequently associated with adverse outcomes: those that are potentially injurious for many in the general geriatric population (independent of diagnosis) and those that are hazardous only under certain conditions. The former include propoxyphene, indomethacin, flurazepam, methyldopa, and chlorpropamide. An example of the latter is prescribing drugs with anticholinergic properties to men with benign prostatic hypertrophy.

Early Recognition

Physicians often fail to recognize ADEs, leading to continuing injury and unnecessary additional therapy and tests. Rochon and Gurwitz136 have described the "prescribing cascade," which occurs when an ADE is misinterpreted as a newly acquired illness. This can lead to additional prescribed therapy for this "new illness," which places the patient at risk for additional harm from the use of drugs. An example is extrapyramidal symptoms developing after initiating metoclopramide therapy, which leads to drug therapy for (erroneously) presumed parkinsonism.

Reducing Unnecessary Drug Use and Substitution With Safer Treatments

Reducing the excessive use of medications requires periodic reviews of medications. Nonpharmacological sleep protocols for inpatients, for example, are an effective means of reducing ADEs.137

Increased Utilization of Pharmacists

Pharmacists are an underused resource for preventing medication errors. Pharmacists provide important safeguards for older patients in hospitals and nursing homes.138,139 Their roles should be expanded to other settings.

Organizational Initiatives

The Food and Drug Administration in 1998 began to implement geriatric drug use labeling requirements. This rule requires drug manufacturers to include labeling with geriatric-specific precautions, indications, and dosing modifications for drugs with predominantly renal-dependent excretion.140 Initially, 6 drug categories will require this labeling improvement: psychotropic agents, nonsteroidal anti-inflammatory agents, certain cardiac drugs, oral hypoglycemic agents, anticoagulants, and quinolone antibiotics.

Falls and Restraints

Fall consultation services have reduced nursing home falls by 19% and fall-related injuries by 31%.53 Successful fall prevention programs target high-risk patients and are cost-effective.141144 In the home setting, Tinetti et al141 achieved a 31% reduction in fall rates by use of a multifactorial intervention program that included medication review, education, training in gait and transfer skills, changes in environmental hazards, strengthening exercises, and behavioral modifications. Some geriatric clinics have used computerized fall risk factor databases to improve identification of patients in greatest need of fall prevention efforts.145

Nosocomial Infections

The prevention of nosocomial infections in older patients requires following sound health care principles that are applicable to all ages: frequent hand washing, appropriate wound and skin care, immunization, and isolation of contagious individuals. Decreasing prolonged use of broad-spectrum antibiotics or invasive devices (endotracheal tubes, nasogastric tubes, indwelling urinary catheters, and central venous catheters) can reduce infections.62,146,147

Pressure Sores

Pressure sore prevention begins with early risk assessment to identify patients most likely to benefit from prevention strategies.67 Commonly used risk assessment tools are the Norton and Braden Scales. Staff education alone can reduce hospital-acquired pressure sores by more than half.148 Prevention addresses mechanical loading due to immobility, the nature of support surfaces, skin care, moisture, incontinence, nutrition, earlier clinical recognition, improved wound care, and education. On-line decision support systems to assist in documentation and provide guideline-based recommendations have resulted in a 60% reduction in pressure sores during a 6-month period.149

Delirium

Hospital-acquired delirium, especially for postoperative patients, is amenable to prevention. Risk assessment, as for other types of preventable injuries, allows for programs to efficiently target high-risk elderly patients. Several delirium prediction models have been developed.82,150,151 In a prospective study, Inouye et al73 found a one third reduction in delirium for hospitalized older patients who undergo a multicomponent intervention to reduce risk factors. A geriatric-anesthesiologist team intervention program has also been able to reduce the incidence of postoperative delirium.92

Surgical and Perioperative Complications

The prevention of surgical complications requires attention to all phases of treatment, beginning with preoperative determination of the appropriateness for the planned procedure. Elderly patients require careful medical assessment by the surgeon, primary care provider, and anesthesiologist.152 Collaboration by such physician teams should continue throughout the hospitalization. Preoperative preparation includes stabilization of active medical problems. Intraoperative management requires attention to proved age-adjusted approaches.153 The postoperative period is particularly prone to complications that are a consequence of bed rest, pain management, and several predictable physiologic responses.

Effective pain management in older patients requires recognition of and adjustment to differences in pharmacological metabolism, excretion, and sensitivity.152 Patient-controlled analgesia has been successively demonstrated to reduce complications in elderly persons, including those who are frail.154

Even though medical therapy is beneficial in the aggregate for elderly patients, the risks of accidental injury are high, especially for certain complications and injuries. However, these risks can be greatly reduced by application of principles and techniques that have been learned in recent years from error prevention and geriatric research. Major improvements could be realized if these principles and techniques were applied more widely in all care settings. As the recent Institute of Medicine report outlines, building a safer health system will require a national comprehensive strategic agenda.1 With careful and expert care, older patients can achieve better health outcomes. Improving our systems to provide that care is a major challenge to medicine.

Accepted for publication June 22, 2000.

This study was supported in part by a grant from the American Association of Retired Persons, Washington, DC.

We thank the following organizations and individuals: the Center for Health System's Research and Analysis, David Zimmerman, PhD; the Veterans Affairs National Surgical Quality Improvement Program, Jennifer Daley, MD, Shukri Khuri, MD, and Kwan Hur, MS; and Jane Soukup, Tony Yu, MD, and Kirsten Shu for their research assistance.

Reprints: Jeffrey M. Rothschild, MD, MPH, Division of General Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (e-mail: jrothschild@partners.org).

Kohn  LTCorrigan  JMDonaldson  MS To Err Is Human: Building a Safer Health System  Washington, DC National Academy Press1999;
Administration on Aging, Profile of older Americans: 1999. Available at: http://www.aoa.dhhs.gov/aoa/stats/profile. Accessed November 27, 1998
Sager  MARudberg  MAJalaluddin  M  et al.  Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc. 1996;44251- 257
Evans  JMChutka  DSFleming  KCTangalos  EGVittone  JHeathman  JH Medical care of nursing home residents. Mayo Clin Proc. 1995;70694- 702
Link to Article
Shaughnessy  PWKramer  AM The increased needs of patients in nursing homes and patients receiving home health care. N Engl J Med. 1990;32221- 27
Link to Article
Rothkopf  MMRothkopf  GS Standards and Practice of Homecare Therapeutics  Baltimore, Md Williams & Wilkins1997;10
Welch  HGWennberg  DEWelch  WP The use of Medicare home health care services. N Engl J Med. 1996;335324- 329
Link to Article
Boling  PA The Physician's Role in Home Health Care  New York, NY Springer Publishing Co Inc1997;
Gillick  MRSerrell  NAGillick  LS Adverse consequences of hospitalization in the elderly. Soc Sci Med. 1982;161033- 1038
Link to Article
Gorbien  MJBishop  JBeers  MHNorman  DOsterweil  DRubenstein  LZ Iatrogenic illness in hospitalized elderly people. J Am Geriatr Soc. 1992;401031- 1042
Gurwitz  JHSanchez-Cross  MTEckler  MAMatulis  J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994;4233- 38
Brennan  TALeape  LLLaird  NM  et al.  Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324370- 376
Link to Article
Leape  LL Error in medicine. JAMA. 1994;2721851- 1857
Link to Article
Reichel  W Complications in the care of five hundred elderly hospitalized patients. J Am Geriatr Soc. 1965;13973- 981
Jahnigen  DHannon  CLaxson  LLaForce  FM Iatrogenic disease in hospitalized elderly veterans. J Am Geriatr Soc. 1982;30387- 390
Gurwitz  JHSanchez-Cross  MTEckler  MAMatulis  J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994;4233- 38
Not Available, Health Care Financing Administration: MDS 2.0 Information Site. Development of MDS-based module for short-stay and clinically intense SNF patients, rehabilitation hospitals and long term care hospitals. Available at: http://www.hcfa.gov/medicare/hsqb/mds20. Accessed July 30, 2000
Do  ANRay  BJBanerjee  SN  et al.  Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. J Infect Dis. 1999;179442- 448
Link to Article
Danzig  LEShort  LJCollins  K  et al.  Bloodstream infections associated with a needleless intravenous infusion system in patients receiving home infusion therapy. JAMA. 1995;2731862- 1864
Link to Article
Gambassi  GLandi  FPeng  L  et al.  Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. Med Care. 1998;36167- 179
Link to Article
Arling  GKaron  SLSainfort  FZimmerman  DRRoss  R Risk adjustment of nursing home quality indicators. Gerontologist. 1997;37757- 766
Link to Article
Leape  LLBrennan  TALaird  N  et al.  The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324377- 384
Link to Article
Bates  DWPruess  KSouney  PPlatt  R Serious falls in hospitalized patients: correlates and resource utilization. Am J Med. 1995;99137- 143
Link to Article
Classen  DCPestotnik  SLEvans  RSLloyd  JFBurke  JP Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277301- 306
Link to Article
Hutchinson  TAFlegel  KMKramer  MSLeduc  DGKong  HH Frequency, severity and risk factors for adverse drug reactions in adult out-patients: a prospective study. J Chronic Dis. 1986;39533- 542
Link to Article
Hanlon  JTSchmader  KEKoronkowski  MJ  et al.  Adverse drug events in high risk older outpatients. J Am Geriatr Soc. 1997;45945- 948
Colt  HGShapiro  AP Drug-induced illness as a cause for admission to a community hospital. J Am Geriatr Soc. 1989;37323- 326
Lamy  PP The elderly and drug interactions. J Am Geriatr Soc. 1986;34586- 592
Carbonin  PPahor  MBernabei  RSgadari  A Is age an independent risk factor of adverse drug reactions in hospitalized medical patients? J Am Geriatr Soc. 1991;391093- 1099
Gray  SLSager  MLestico  MRJalaluddin  M Adverse drug events in hospitalized elderly. J Gerontol A Biol Sci Med Sci. 1998;53M59- M63
Link to Article
Bates  DWCullen  DJLaird  N  et al. ADE Prevention Study Group, Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;27429- 34
Link to Article
Classen  DCPestotnik  SLEvans  RSBurke  JP Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;2662847- 2851
Link to Article
Hurwitz  N Predisposing factors in adverse reactions to drugs. BMJ. 1969;1536- 539
Link to Article
Williamson  JChopin  JM Adverse reactions to prescribed drugs in the elderly: a multicentre investigation. Age Ageing. 1980;973- 80
Link to Article
Cooper  JW Probable adverse drug reactions in a rural geriatric nursing home population: a four-year study. J Am Geriatr Soc. 1996;44194- 197
Gerety  MBCornell  JEPlichta  DTEimer  M Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc. 1993;411326- 1332
Klein  LEGerman  PSLevine  DMFeroli  ERJArdery  J Medication problems among outpatients: a study with emphasis on the elderly. Arch Intern Med. 1984;1441185- 1188
Link to Article
Schneider  JKMion  LCFrengley  JD Adverse drug reactions in an elderly outpatient population. Am J Hosp Pharm. 1992;4990- 96
Stuck  AEBeers  MHSteiner  AAronow  HURubenstein  LZBeck  JC Inappropriate medication use in community-residing older persons. Arch Intern Med. 1994;1542195- 2200
Link to Article
Willcox  SMHimmelstein  DUWoolhandler  S Inappropriate drug prescribing for the community-dwelling elderly. JAMA. 1994;272292- 296
Link to Article
Aparasu  RRFliginger  SE Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother. 1997;31823- 829
O'Loughlin  JLRobitaille  YBoivin  JFSuissa  S Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137342- 354
Bianchetti  AZanetti  ORossini  R  et al.  Risk factors for the development of pressure sores in hospitalized patients: results of a prospective study. Arch Gerontol Geriatr. 1993;16225- 230
Link to Article
Brandeis  GHBerlowitz  DRHossain  MMorris  JN Pressure ulcers: the minimum data set and the resident assessment protocol. Adv Wound Care. 1995;818- 25
Schor  JDLevkoff  SELipsitz  LA  et al.  Risk factors for delirium in hospitalized elderly. JAMA. 1992;267827- 831
Link to Article
Inouye  SKCharpentier  PA Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275852- 857
Link to Article
Myers  AHBaker  SPVan Natta  MLAbbey  HRobinson  EG Risk factors associated with falls and injuries among elderly institutionalized persons. Am J Epidemiol. 1991;1331179- 1190
Thapa  PBBrockman  KGGideon  PFought  RLRay  WA Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors. J Am Geriatr Soc. 1996;44273- 278
King  MBTinetti  ME Falls in community-dwelling older persons. J Am Geriatr Soc. 1995;431146- 1154
Tinetti  MEDoucette  JTClaus  EB The contribution of predisposing and situational risk factors to serious fall injuries. J Am Geriatr Soc. 1995;431207- 1213
Mahoney  JETinetti  ME Immobility and falls: factors associated with serious injury during falls by ambulatory nursing home residents. Clin Geriatr Med. 1998;14699- 726
Morgan  VRMathison  JHRice  JCClemmer  DI Hospital falls: a persistent problem. Am J Public Health. 1985;75775- 777
Link to Article
Ray  WATaylor  JAMeador  KG  et al.  A randomized trial of a consultation service to reduce falls in nursing homes. JAMA. 1997;278557- 562
Link to Article
Tinetti  MESpeechley  MGinter  SF Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;3191701- 1707
Link to Article
Morrison  RSChassin  MRSiu  AL The medical consultant's role in caring for patients with hip fracture. Ann Intern Med. 1998;1281010- 1020
Link to Article
Frengley  JDMion  LCMahoney  JE Physical restraints in the acute care setting: issues and future direction immobility and falls. Clin Geriatr Med. 1998;14727- 743
Tinetti  MELiu  WLGinter  SF Mechanical restraint use and fall-related injuries among residents of skilled nursing facilities. Ann Intern Med. 1992;116369- 374
Link to Article
Capezuti  EEvans  LStrumpf  NMaislin  G Physical restraint use and falls in nursing home residents. J Am Geriatr Soc. 1996;44627- 633
Evans  LKStrumpf  NE Tying down the elderly: a review of the literature on physical restraint. J Am Geriatr Soc. 1989;3765- 74
Norman  DCCastle  SCCantrell  M Infections in the nursing home. J Am Geriatr Soc. 1987;35796- 805
Franson  TRDuthie  EHJCooper  JEVan Oudenhoven  GHoffmann  RG Prevalence survey of infections and their predisposing factors at a hospital-based nursing home care unit. J Am Geriatr Soc. 1986;3495- 100
Riedinger  JLRobbins  LJBergstrom  NI Prevention of iatrogenic illness: adverse drug reactions and nosocomial infections in hospitalized older adults: strategies for preventing pressure ulcers. Clin Geriatr Med. 1998;14681- 698
Gross  PARapuano  CAdrignolo  AShaw  B Nosocomial infections: decade-specific risk. Infect Control. 1983;4145- 147
Magaziner  JTenney  JHDeForge  BHebel  JRMuncie  HLJWarren  JW Prevalence and characteristics of nursing home–acquired infections in the aged. J Am Geriatr Soc. 1991;391071- 1078
Muder  RRBrennen  CSwenson  DLWagener  M Pneumonia in a long-term care facility: a prospective study of outcome. Arch Intern Med. 1996;1562365- 2370
Link to Article
Muder  RR Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention. Am J Med. 1998;105319- 330
Link to Article
Evans  JMAndrews  KLChutka  DSFleming  KCGarness  SL Pressure ulcers: prevention and management. Mayo Clin Proc. 1995;70789- 799
Link to Article
Allman  RM The impact of pressure ulcers on health care costs and mortality. Adv Wound Care. 1998;11 ((3 suppl)) 2
Guralnik  JMHarris  TBWhite  LRCornoni-Huntley  JC Occurrence and predictors of pressure sores in the National Health and Nutrition Examination survey follow-up. J Am Geriatr Soc. 1988;36807- 812
Allman  RM Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med. 1997;13421- 436
Brandeis  GHMorris  JNNash  DJLipsitz  LA The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA. 1990;2642905- 2909
Link to Article
Bergstrom  NBraden  B A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc. 1992;40747- 758
Inouye  SKBogardus  STCharpentier  PA  et al.  A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340669- 676
Link to Article
Inouye  SKRichardson  JBresland  K Delirium in hospitalized older patients: the management of postsurgical pain in the elderly population. Clin Geriatr Med. 1998;14745- 764
Inouye  SK The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med. 1994;97278- 288
Link to Article
Inouye  SKRushing  JTForeman  MDPalmer  RMPompei  P Does delirium contribute to poor hospital outcomes? a three-site epidemiologic study. J Gen Intern Med. 1998;13234- 242
Link to Article
Pompei  PForeman  MRudberg  MAInouye  SKBraund  VCassel  CK Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc. 1994;42809- 815
Elie  MCole  MGPrimeau  FJBellavance  F Delirium risk factors in elderly hospitalized patients. J Gen Intern Med. 1998;13204- 212
Link to Article
Gawande  AAThomas  EJZinner  MJBrennan  TA The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;12666- 75
Link to Article
Keller  SMMarkovitz  LJWilder  JRAufses  AHJ Emergency and elective surgery in patients over age 70. Am Surg. 1987;53636- 640
Potts  SFeinglass  JLefevere  FKadah  HBranson  CWebster  J A quality-of-care analysis of cascade iatrogenesis in frail elderly hospital patients. QRB Qual Rev Bull. 1993;19199- 205
Inouye  SKViscoli  CMHorwitz  RIHurst  LDTinetti  ME A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med. 1993;119474- 481
Link to Article
Resnick  NMMarcantonio  ER How should clinical care of the aged differ? Lancet. 1997;3501157- 1158
Link to Article
Rich  MWShah  ASVinson  JMFreedland  KEKuru  TSperry  JC Iatrogenic congestive heart failure in older adults: clinical course and prognosis. J Am Geriatr Soc. 1996;44638- 643
Davidman  MOlson  PKohen  JLeither  TKjellstrand  C Iatrogenic renal disease. Arch Intern Med. 1991;1511809- 1812
Link to Article
Radecki  SEKane  RLSolomon  DHMendenhall  RCBeck  JC Are physicians sensitive to the special problems of older patients? J Am Geriatr Soc. 1988;36719- 725
Gurwitz  JHAvorn  J The ambiguous relation between aging and adverse drug reactions. Ann Intern Med. 1991;114956- 966
Link to Article
Bates  DWMiller  ECullen  D  et al.  Risk factors for adverse drug events in hospitalized patients. Arch Intern Med. 1999;1592553- 2560
Link to Article
Perry  BC Falls among the elderly: a review of the methods and conclusions of epidemiologic studies. J Am Geriatr Soc. 1982;30367- 371
Rubenstein  LZRobbins  ASSchulman  BLRosado  JOsterweil  DJosephson  KR Falls and instability in the elderly. J Am Geriatr Soc. 1988;36266- 278
Monane  MAvorn  J Medications and falls: causation, correlation, and prevention. Clin Geriatr Med. 1996;12847- 858
Gustafson  YBrannstrom  BBerggren  D  et al.  A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc. 1991;39655- 662
Thapa  PBGideon  PCost  TWMilam  ABRay  WA Antidepressants and the risk of falls among nursing home residents. N Engl J Med. 1998;339875- 882
Link to Article
Hanson  LCWeber  DJRutala  WA Risk factors for nosocomial pneumonia in the elderly. Am J Med. 1992;92161- 166
Link to Article
Medina-Walpole  AMMcCormick  WC Provider practice patterns in nursing home–acquired pneumonia. J Am Geriatr Soc. 1998;46187- 192
Pick  NMcDonald  ABennett  N  et al.  Pulmonary aspiration in a long-term care setting: clinical and laboratory observations and an analysis of risk factors. J Am Geriatr Soc. 1996;44763- 768
Farber  BFBrennen  CPuntereri  AJBrody  JP A prospective study of nosocomial infections in a chronic care facility. J Am Geriatr Soc. 1984;32499- 502
Alvarez  SShell  CGWoolley  TWBerk  SLSmith  JK Nosocomial infections in long-term facilities. J Gerontol. 1988;43M9- M17
Link to Article
Hussain  MOppenheim  BAO'Neill  PTrembath  CMorris  JHoran  MA Prospective survey of the incidence, risk factors and outcome of hospital-acquired infections in the elderly. J Hosp Infect. 1996;32117- 126
Link to Article
Stead  WWLofgren  JPWarren  EThomas  C Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes. N Engl J Med. 1985;3121483- 1487
Link to Article
Allman  RMGoode  PSPatrick  MMBurst  NBartolucci  AA Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA. 1995;273865- 870
Link to Article
Allman  RMLaprade  CANoel  LB  et al.  Pressure sores among hospitalized patients. Ann Intern Med. 1986;105337- 342
Link to Article
Dodds  CAllison  J Postoperative cognitive deficit in the elderly surgical patient. Br J Anaesth. 1998;81449- 462
Link to Article
Parikh  SSChung  F Postoperative delirium in the elderly. Anesth Analg. 1995;801223- 1232
Lynch  EPLazor  MAGellis  JEOrav  JGoldman  LMarcantonio  ER The impact of postoperative pain on the development of postoperative delirium. Anesth Analg. 1998;86781- 785
Francis  J Delirium in older patients. J Am Geriatr Soc. 1992;40829- 838
Vroman  GKohen  IVolkman  N Misinterpreting cognitive decline. Bogner  MSed.Human Error in Medicine. Hillsdale, NJ Lawrence A Erlbaum Associates1994;93- 122
Burns-Cox  NCampbell  WBvan Nimmen  BAVercaeren  PMLucarotti  M Surgical care and outcome for patients in their nineties. Br J Surg. 1997;84496- 498
Link to Article
Daley  JKhuri  SFHenderson  W  et al.  Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg. 1997;185328- 340
Khuri  SFDaley  JHenderson  W  et al.  The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180519- 531
Khuri  SFDaley  JHenderson  W  et al.  Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg. 1997;185315- 327
Fowkes  FGLunn  JNFarrow  SCRobertson  IBSamuel  P Epidemiology in anaesthesia, III: mortality risk in patients with coexisting physical disease. Br J Anaesth. 1982;54819- 825
Link to Article
Vaz  FGSeymour  DG A prospective study of elderly general surgical patients, I: pre-operative medical problems. Age Ageing. 1989;18309- 315
Link to Article
Linn  BSLinn  MWWallen  N Evaluation of results of surgical procedures in the elderly. Ann Surg. 1982;19590- 96
Link to Article
Edwards  AESeymour  DGMcCarthy  JMCrumplin  MK A 5-year survival study of general surgical patients aged 65 years and over. Anaesthesia. 1996;513- 10
Link to Article
Kresevic  DHolder  CMurtaugh  CMKemper  PSpillman  BCCarlson  BL Interdisciplinary care: the amount, distribution, and timing of lifetime nursing home use. Clin Geriatr Med. 1998;14787- 798
Leape  LLBates  DWCullen  DJ  et al. ADE Prevention Study Group, Systems analysis of adverse drug events. JAMA. 1995;27435- 43
Link to Article
Berwick  DM Continuous improvement as an ideal in health care. N Engl J Med. 1989;32053- 56
Link to Article
Bates  DWSpell  NCullen  DJ  et al. Adverse Drug Events Prevention Study Group, The costs of adverse drug events in hospitalized patients. JAMA. 1997;277307- 311
Link to Article
Not Available, Sentinel events: approaches to error reduction and prevention. Jt Comm J Qual Improv. 1998;24175- 186
Welch  HGAlbertsen  PCNease  RFBubolz  TAWasson  JH Estimating treatment benefits for the elderly: the effect of competing risks. Ann Intern Med. 1996;124577- 584
Link to Article
Ezekowitz  MDLevine  JA Preventing stroke in patients with atrial fibrillation. JAMA. 1999;2811830- 1835
Link to Article
Brook  RHKamberg  CJMayer-Oakes  ABeers  MHRaube  KSteiner  A Appropriateness of acute medical care for the elderly: an analysis of the literature. Health Policy. 1990;14225- 242
Link to Article
Resnick  NMMarcantonio  ER How should clinical care of the aged differ? Lancet. 1997;3501157- 1158
Link to Article
Becker  PMMcVey  LJSaltz  CCFeussner  JRCohen  HJ Hospital-acquired complications in a randomized controlled clinical trial of a geriatric consultation team. JAMA. 1987;2572313- 2317
Link to Article
Covinsky  KEPalmer  RMKresevic  DM  et al.  Improving functional outcomes in older patients: lessons from an acute care for elders unit. Jt Comm J Qual Improv. 1998;2463- 76
Landefeld  CSPalmer  RMKresevic  DMFortinsky  RHKowal  J A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;3321338- 1344
Link to Article
Palmer  RMLandefeld  CSKresevic  DKowal  J A medical unit for the acute care of the elderly. J Am Geriatr Soc. 1994;42545- 552
Stuck  AESiu  ALWieland  GDAdams  JRubenstein  LZ Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993;3421032- 1036
Link to Article
Naylor  MBrooten  DCampbell  R  et al.  Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281613- 620
Link to Article
Naylor  MBrooten  DJones  RLavizzo-Mourey  RMezey  MPauly  M Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. Ann Intern Med. 1994;120999- 1006
Link to Article
Bates  DWLeape  LLCullen  DJ  et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;2801311- 1316
Link to Article
Schiff  GDRucker  TD Computerized prescribing: building the electronic infrastructure for better medication usage. JAMA. 1998;2791024- 1029
Link to Article
Monane  MMatthias  DMNagle  BAKelly  MA Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. JAMA. 1998;2801249- 1252
Link to Article
Beers  MH Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med. 1997;1571531- 1536
Link to Article
Rochon  PAGurwitz  JH Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;3151096- 1099
Link to Article
McDowell  JAMion  LCLydon  TJInouye  SK A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46700- 705
Hsia  DERubenstein  LZChoy  GS The benefits of in-home pharmacy evaluation for older persons. J Am Geriatr Soc. 1997;45211- 214
Leape  LLCullen  DJClapp  MD  et al.  Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282267- 270
Link to Article
Skolnick  AA FDA sets geriatric drug use labeling deadlines. JAMA. 1997;2781302
Link to Article
Tinetti  MEBaker  DIMcAvay  G  et al.  A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331821- 827
Link to Article
Province  MAHadley  ECHornbrook  MC  et al.  The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials: frailty and injuries: cooperative studies of intervention techniques. JAMA. 1995;2731341- 1347
Link to Article
Close  JEllis  MHooper  RGlucksman  EJackson  SSwift  C Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet. 1999;35393- 97
Link to Article
Rizzo  JABaker  DIMcAvay  GTinetti  ME The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Med Care. 1996;34954- 969
Link to Article
Dyer  CAEWatkins  CLGould  CRowe  J Risk-factor assessment for falls: from a written checklist to the penless clinic. Age Ageing. 1998;27569- 572
Link to Article
Hanson  LCWeber  DJRutala  WA Risk factors for nosocomial pneumonia in the elderly. Am J Med. 1992;92161- 166
Link to Article
Saviteer  SMSamsa  GPRutala  WA Nosocomial infections in the elderly: increased risk per hospital day. Am J Med. 1988;84661- 666
Link to Article
Moody  BLFanale  JEThompson  MVaillancourt  DSymonds  GBonasoro  C Impact of staff education on pressure sore development in elderly hospitalized patients. Arch Intern Med. 1988;1482241- 2243
Link to Article
Bergstrom  NI Strategies for preventing pressure ulcers. Clin Geriatr Med. 1997;13437- 454
Marcantonio  ERGoldman  LMangione  CM  et al.  A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271134- 139
Link to Article
Fisher  BWFlowerdew  G A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery. J Am Geriatr Soc. 1995;43175- 178
Muravchick  S Geroanesthesia: Principles for Management of the Elderly  St Louis, Mo Mosby–Year Book Inc1997;
Raja  SNHaythornthwaite  JA Anesthetic management of the elderly. Anesthesiology. 1999;91901- 911
Link to Article
Egbert  AMParks  LHShort  LMBurnett  ML Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men. Arch Intern Med. 1990;1501897- 1903
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Harvard Medical Practice Study: Injuries in Older Patients*
Table Graphic Jump LocationTable 2. Center for Health Systems Research and Analysis Multiple Data Set 2.0: Mean Prevalence Rates for Selected Quality Indicators
Table Graphic Jump LocationTable 3. Falls, Pressure Sores, and Inpatient Delirium*
Table Graphic Jump LocationTable 4. VA National Surgical Quality Improvement Program: Incidence of Selected Risk Factors and Outcomes*
Table Graphic Jump LocationTable 5. VA National Surgical Quality Improvement: Incidence of Selected Postoperative Complications After Major Surgery Among Veterans (Fiscal Year 1998)*
Table Graphic Jump LocationTable 6. Error Prevention Strategies for Older Patients (≥65 Years)

References

Kohn  LTCorrigan  JMDonaldson  MS To Err Is Human: Building a Safer Health System  Washington, DC National Academy Press1999;
Administration on Aging, Profile of older Americans: 1999. Available at: http://www.aoa.dhhs.gov/aoa/stats/profile. Accessed November 27, 1998
Sager  MARudberg  MAJalaluddin  M  et al.  Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc. 1996;44251- 257
Evans  JMChutka  DSFleming  KCTangalos  EGVittone  JHeathman  JH Medical care of nursing home residents. Mayo Clin Proc. 1995;70694- 702
Link to Article
Shaughnessy  PWKramer  AM The increased needs of patients in nursing homes and patients receiving home health care. N Engl J Med. 1990;32221- 27
Link to Article
Rothkopf  MMRothkopf  GS Standards and Practice of Homecare Therapeutics  Baltimore, Md Williams & Wilkins1997;10
Welch  HGWennberg  DEWelch  WP The use of Medicare home health care services. N Engl J Med. 1996;335324- 329
Link to Article
Boling  PA The Physician's Role in Home Health Care  New York, NY Springer Publishing Co Inc1997;
Gillick  MRSerrell  NAGillick  LS Adverse consequences of hospitalization in the elderly. Soc Sci Med. 1982;161033- 1038
Link to Article
Gorbien  MJBishop  JBeers  MHNorman  DOsterweil  DRubenstein  LZ Iatrogenic illness in hospitalized elderly people. J Am Geriatr Soc. 1992;401031- 1042
Gurwitz  JHSanchez-Cross  MTEckler  MAMatulis  J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994;4233- 38
Brennan  TALeape  LLLaird  NM  et al.  Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324370- 376
Link to Article
Leape  LL Error in medicine. JAMA. 1994;2721851- 1857
Link to Article
Reichel  W Complications in the care of five hundred elderly hospitalized patients. J Am Geriatr Soc. 1965;13973- 981
Jahnigen  DHannon  CLaxson  LLaForce  FM Iatrogenic disease in hospitalized elderly veterans. J Am Geriatr Soc. 1982;30387- 390
Gurwitz  JHSanchez-Cross  MTEckler  MAMatulis  J The epidemiology of adverse and unexpected events in the long-term care setting. J Am Geriatr Soc. 1994;4233- 38
Not Available, Health Care Financing Administration: MDS 2.0 Information Site. Development of MDS-based module for short-stay and clinically intense SNF patients, rehabilitation hospitals and long term care hospitals. Available at: http://www.hcfa.gov/medicare/hsqb/mds20. Accessed July 30, 2000
Do  ANRay  BJBanerjee  SN  et al.  Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. J Infect Dis. 1999;179442- 448
Link to Article
Danzig  LEShort  LJCollins  K  et al.  Bloodstream infections associated with a needleless intravenous infusion system in patients receiving home infusion therapy. JAMA. 1995;2731862- 1864
Link to Article
Gambassi  GLandi  FPeng  L  et al.  Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. Med Care. 1998;36167- 179
Link to Article
Arling  GKaron  SLSainfort  FZimmerman  DRRoss  R Risk adjustment of nursing home quality indicators. Gerontologist. 1997;37757- 766
Link to Article
Leape  LLBrennan  TALaird  N  et al.  The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324377- 384
Link to Article
Bates  DWPruess  KSouney  PPlatt  R Serious falls in hospitalized patients: correlates and resource utilization. Am J Med. 1995;99137- 143
Link to Article
Classen  DCPestotnik  SLEvans  RSLloyd  JFBurke  JP Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277301- 306
Link to Article
Hutchinson  TAFlegel  KMKramer  MSLeduc  DGKong  HH Frequency, severity and risk factors for adverse drug reactions in adult out-patients: a prospective study. J Chronic Dis. 1986;39533- 542
Link to Article
Hanlon  JTSchmader  KEKoronkowski  MJ  et al.  Adverse drug events in high risk older outpatients. J Am Geriatr Soc. 1997;45945- 948
Colt  HGShapiro  AP Drug-induced illness as a cause for admission to a community hospital. J Am Geriatr Soc. 1989;37323- 326
Lamy  PP The elderly and drug interactions. J Am Geriatr Soc. 1986;34586- 592
Carbonin  PPahor  MBernabei  RSgadari  A Is age an independent risk factor of adverse drug reactions in hospitalized medical patients? J Am Geriatr Soc. 1991;391093- 1099
Gray  SLSager  MLestico  MRJalaluddin  M Adverse drug events in hospitalized elderly. J Gerontol A Biol Sci Med Sci. 1998;53M59- M63
Link to Article
Bates  DWCullen  DJLaird  N  et al. ADE Prevention Study Group, Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;27429- 34
Link to Article
Classen  DCPestotnik  SLEvans  RSBurke  JP Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991;2662847- 2851
Link to Article
Hurwitz  N Predisposing factors in adverse reactions to drugs. BMJ. 1969;1536- 539
Link to Article
Williamson  JChopin  JM Adverse reactions to prescribed drugs in the elderly: a multicentre investigation. Age Ageing. 1980;973- 80
Link to Article
Cooper  JW Probable adverse drug reactions in a rural geriatric nursing home population: a four-year study. J Am Geriatr Soc. 1996;44194- 197
Gerety  MBCornell  JEPlichta  DTEimer  M Adverse events related to drugs and drug withdrawal in nursing home residents. J Am Geriatr Soc. 1993;411326- 1332
Klein  LEGerman  PSLevine  DMFeroli  ERJArdery  J Medication problems among outpatients: a study with emphasis on the elderly. Arch Intern Med. 1984;1441185- 1188
Link to Article
Schneider  JKMion  LCFrengley  JD Adverse drug reactions in an elderly outpatient population. Am J Hosp Pharm. 1992;4990- 96
Stuck  AEBeers  MHSteiner  AAronow  HURubenstein  LZBeck  JC Inappropriate medication use in community-residing older persons. Arch Intern Med. 1994;1542195- 2200
Link to Article
Willcox  SMHimmelstein  DUWoolhandler  S Inappropriate drug prescribing for the community-dwelling elderly. JAMA. 1994;272292- 296
Link to Article
Aparasu  RRFliginger  SE Inappropriate medication prescribing for the elderly by office-based physicians. Ann Pharmacother. 1997;31823- 829
O'Loughlin  JLRobitaille  YBoivin  JFSuissa  S Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137342- 354
Bianchetti  AZanetti  ORossini  R  et al.  Risk factors for the development of pressure sores in hospitalized patients: results of a prospective study. Arch Gerontol Geriatr. 1993;16225- 230
Link to Article
Brandeis  GHBerlowitz  DRHossain  MMorris  JN Pressure ulcers: the minimum data set and the resident assessment protocol. Adv Wound Care. 1995;818- 25
Schor  JDLevkoff  SELipsitz  LA  et al.  Risk factors for delirium in hospitalized elderly. JAMA. 1992;267827- 831
Link to Article
Inouye  SKCharpentier  PA Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275852- 857
Link to Article
Myers  AHBaker  SPVan Natta  MLAbbey  HRobinson  EG Risk factors associated with falls and injuries among elderly institutionalized persons. Am J Epidemiol. 1991;1331179- 1190
Thapa  PBBrockman  KGGideon  PFought  RLRay  WA Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors. J Am Geriatr Soc. 1996;44273- 278
King  MBTinetti  ME Falls in community-dwelling older persons. J Am Geriatr Soc. 1995;431146- 1154
Tinetti  MEDoucette  JTClaus  EB The contribution of predisposing and situational risk factors to serious fall injuries. J Am Geriatr Soc. 1995;431207- 1213
Mahoney  JETinetti  ME Immobility and falls: factors associated with serious injury during falls by ambulatory nursing home residents. Clin Geriatr Med. 1998;14699- 726
Morgan  VRMathison  JHRice  JCClemmer  DI Hospital falls: a persistent problem. Am J Public Health. 1985;75775- 777
Link to Article
Ray  WATaylor  JAMeador  KG  et al.  A randomized trial of a consultation service to reduce falls in nursing homes. JAMA. 1997;278557- 562
Link to Article
Tinetti  MESpeechley  MGinter  SF Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;3191701- 1707
Link to Article
Morrison  RSChassin  MRSiu  AL The medical consultant's role in caring for patients with hip fracture. Ann Intern Med. 1998;1281010- 1020
Link to Article
Frengley  JDMion  LCMahoney  JE Physical restraints in the acute care setting: issues and future direction immobility and falls. Clin Geriatr Med. 1998;14727- 743
Tinetti  MELiu  WLGinter  SF Mechanical restraint use and fall-related injuries among residents of skilled nursing facilities. Ann Intern Med. 1992;116369- 374
Link to Article
Capezuti  EEvans  LStrumpf  NMaislin  G Physical restraint use and falls in nursing home residents. J Am Geriatr Soc. 1996;44627- 633
Evans  LKStrumpf  NE Tying down the elderly: a review of the literature on physical restraint. J Am Geriatr Soc. 1989;3765- 74
Norman  DCCastle  SCCantrell  M Infections in the nursing home. J Am Geriatr Soc. 1987;35796- 805
Franson  TRDuthie  EHJCooper  JEVan Oudenhoven  GHoffmann  RG Prevalence survey of infections and their predisposing factors at a hospital-based nursing home care unit. J Am Geriatr Soc. 1986;3495- 100
Riedinger  JLRobbins  LJBergstrom  NI Prevention of iatrogenic illness: adverse drug reactions and nosocomial infections in hospitalized older adults: strategies for preventing pressure ulcers. Clin Geriatr Med. 1998;14681- 698
Gross  PARapuano  CAdrignolo  AShaw  B Nosocomial infections: decade-specific risk. Infect Control. 1983;4145- 147
Magaziner  JTenney  JHDeForge  BHebel  JRMuncie  HLJWarren  JW Prevalence and characteristics of nursing home–acquired infections in the aged. J Am Geriatr Soc. 1991;391071- 1078
Muder  RRBrennen  CSwenson  DLWagener  M Pneumonia in a long-term care facility: a prospective study of outcome. Arch Intern Med. 1996;1562365- 2370
Link to Article
Muder  RR Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention. Am J Med. 1998;105319- 330
Link to Article
Evans  JMAndrews  KLChutka  DSFleming  KCGarness  SL Pressure ulcers: prevention and management. Mayo Clin Proc. 1995;70789- 799
Link to Article
Allman  RM The impact of pressure ulcers on health care costs and mortality. Adv Wound Care. 1998;11 ((3 suppl)) 2
Guralnik  JMHarris  TBWhite  LRCornoni-Huntley  JC Occurrence and predictors of pressure sores in the National Health and Nutrition Examination survey follow-up. J Am Geriatr Soc. 1988;36807- 812
Allman  RM Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med. 1997;13421- 436
Brandeis  GHMorris  JNNash  DJLipsitz  LA The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA. 1990;2642905- 2909
Link to Article
Bergstrom  NBraden  B A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc. 1992;40747- 758
Inouye  SKBogardus  STCharpentier  PA  et al.  A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340669- 676
Link to Article
Inouye  SKRichardson  JBresland  K Delirium in hospitalized older patients: the management of postsurgical pain in the elderly population. Clin Geriatr Med. 1998;14745- 764
Inouye  SK The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med. 1994;97278- 288
Link to Article
Inouye  SKRushing  JTForeman  MDPalmer  RMPompei  P Does delirium contribute to poor hospital outcomes? a three-site epidemiologic study. J Gen Intern Med. 1998;13234- 242
Link to Article
Pompei  PForeman  MRudberg  MAInouye  SKBraund  VCassel  CK Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc. 1994;42809- 815
Elie  MCole  MGPrimeau  FJBellavance  F Delirium risk factors in elderly hospitalized patients. J Gen Intern Med. 1998;13204- 212
Link to Article
Gawande  AAThomas  EJZinner  MJBrennan  TA The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;12666- 75
Link to Article
Keller  SMMarkovitz  LJWilder  JRAufses  AHJ Emergency and elective surgery in patients over age 70. Am Surg. 1987;53636- 640
Potts  SFeinglass  JLefevere  FKadah  HBranson  CWebster  J A quality-of-care analysis of cascade iatrogenesis in frail elderly hospital patients. QRB Qual Rev Bull. 1993;19199- 205
Inouye  SKViscoli  CMHorwitz  RIHurst  LDTinetti  ME A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med. 1993;119474- 481
Link to Article
Resnick  NMMarcantonio  ER How should clinical care of the aged differ? Lancet. 1997;3501157- 1158
Link to Article
Rich  MWShah  ASVinson  JMFreedland  KEKuru  TSperry  JC Iatrogenic congestive heart failure in older adults: clinical course and prognosis. J Am Geriatr Soc. 1996;44638- 643
Davidman  MOlson  PKohen  JLeither  TKjellstrand  C Iatrogenic renal disease. Arch Intern Med. 1991;1511809- 1812
Link to Article
Radecki  SEKane  RLSolomon  DHMendenhall  RCBeck  JC Are physicians sensitive to the special problems of older patients? J Am Geriatr Soc. 1988;36719- 725
Gurwitz  JHAvorn  J The ambiguous relation between aging and adverse drug reactions. Ann Intern Med. 1991;114956- 966
Link to Article
Bates  DWMiller  ECullen  D  et al.  Risk factors for adverse drug events in hospitalized patients. Arch Intern Med. 1999;1592553- 2560
Link to Article
Perry  BC Falls among the elderly: a review of the methods and conclusions of epidemiologic studies. J Am Geriatr Soc. 1982;30367- 371
Rubenstein  LZRobbins  ASSchulman  BLRosado  JOsterweil  DJosephson  KR Falls and instability in the elderly. J Am Geriatr Soc. 1988;36266- 278
Monane  MAvorn  J Medications and falls: causation, correlation, and prevention. Clin Geriatr Med. 1996;12847- 858
Gustafson  YBrannstrom  BBerggren  D  et al.  A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc. 1991;39655- 662
Thapa  PBGideon  PCost  TWMilam  ABRay  WA Antidepressants and the risk of falls among nursing home residents. N Engl J Med. 1998;339875- 882
Link to Article
Hanson  LCWeber  DJRutala  WA Risk factors for nosocomial pneumonia in the elderly. Am J Med. 1992;92161- 166
Link to Article
Medina-Walpole  AMMcCormick  WC Provider practice patterns in nursing home–acquired pneumonia. J Am Geriatr Soc. 1998;46187- 192
Pick  NMcDonald  ABennett  N  et al.  Pulmonary aspiration in a long-term care setting: clinical and laboratory observations and an analysis of risk factors. J Am Geriatr Soc. 1996;44763- 768
Farber  BFBrennen  CPuntereri  AJBrody  JP A prospective study of nosocomial infections in a chronic care facility. J Am Geriatr Soc. 1984;32499- 502
Alvarez  SShell  CGWoolley  TWBerk  SLSmith  JK Nosocomial infections in long-term facilities. J Gerontol. 1988;43M9- M17
Link to Article
Hussain  MOppenheim  BAO'Neill  PTrembath  CMorris  JHoran  MA Prospective survey of the incidence, risk factors and outcome of hospital-acquired infections in the elderly. J Hosp Infect. 1996;32117- 126
Link to Article
Stead  WWLofgren  JPWarren  EThomas  C Tuberculosis as an endemic and nosocomial infection among the elderly in nursing homes. N Engl J Med. 1985;3121483- 1487
Link to Article
Allman  RMGoode  PSPatrick  MMBurst  NBartolucci  AA Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA. 1995;273865- 870
Link to Article
Allman  RMLaprade  CANoel  LB  et al.  Pressure sores among hospitalized patients. Ann Intern Med. 1986;105337- 342
Link to Article
Dodds  CAllison  J Postoperative cognitive deficit in the elderly surgical patient. Br J Anaesth. 1998;81449- 462
Link to Article
Parikh  SSChung  F Postoperative delirium in the elderly. Anesth Analg. 1995;801223- 1232
Lynch  EPLazor  MAGellis  JEOrav  JGoldman  LMarcantonio  ER The impact of postoperative pain on the development of postoperative delirium. Anesth Analg. 1998;86781- 785
Francis  J Delirium in older patients. J Am Geriatr Soc. 1992;40829- 838
Vroman  GKohen  IVolkman  N Misinterpreting cognitive decline. Bogner  MSed.Human Error in Medicine. Hillsdale, NJ Lawrence A Erlbaum Associates1994;93- 122
Burns-Cox  NCampbell  WBvan Nimmen  BAVercaeren  PMLucarotti  M Surgical care and outcome for patients in their nineties. Br J Surg. 1997;84496- 498
Link to Article
Daley  JKhuri  SFHenderson  W  et al.  Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg. 1997;185328- 340
Khuri  SFDaley  JHenderson  W  et al.  The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180519- 531
Khuri  SFDaley  JHenderson  W  et al.  Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg. 1997;185315- 327
Fowkes  FGLunn  JNFarrow  SCRobertson  IBSamuel  P Epidemiology in anaesthesia, III: mortality risk in patients with coexisting physical disease. Br J Anaesth. 1982;54819- 825
Link to Article
Vaz  FGSeymour  DG A prospective study of elderly general surgical patients, I: pre-operative medical problems. Age Ageing. 1989;18309- 315
Link to Article
Linn  BSLinn  MWWallen  N Evaluation of results of surgical procedures in the elderly. Ann Surg. 1982;19590- 96
Link to Article
Edwards  AESeymour  DGMcCarthy  JMCrumplin  MK A 5-year survival study of general surgical patients aged 65 years and over. Anaesthesia. 1996;513- 10
Link to Article
Kresevic  DHolder  CMurtaugh  CMKemper  PSpillman  BCCarlson  BL Interdisciplinary care: the amount, distribution, and timing of lifetime nursing home use. Clin Geriatr Med. 1998;14787- 798
Leape  LLBates  DWCullen  DJ  et al. ADE Prevention Study Group, Systems analysis of adverse drug events. JAMA. 1995;27435- 43
Link to Article
Berwick  DM Continuous improvement as an ideal in health care. N Engl J Med. 1989;32053- 56
Link to Article
Bates  DWSpell  NCullen  DJ  et al. Adverse Drug Events Prevention Study Group, The costs of adverse drug events in hospitalized patients. JAMA. 1997;277307- 311
Link to Article
Not Available, Sentinel events: approaches to error reduction and prevention. Jt Comm J Qual Improv. 1998;24175- 186
Welch  HGAlbertsen  PCNease  RFBubolz  TAWasson  JH Estimating treatment benefits for the elderly: the effect of competing risks. Ann Intern Med. 1996;124577- 584
Link to Article
Ezekowitz  MDLevine  JA Preventing stroke in patients with atrial fibrillation. JAMA. 1999;2811830- 1835
Link to Article
Brook  RHKamberg  CJMayer-Oakes  ABeers  MHRaube  KSteiner  A Appropriateness of acute medical care for the elderly: an analysis of the literature. Health Policy. 1990;14225- 242
Link to Article
Resnick  NMMarcantonio  ER How should clinical care of the aged differ? Lancet. 1997;3501157- 1158
Link to Article
Becker  PMMcVey  LJSaltz  CCFeussner  JRCohen  HJ Hospital-acquired complications in a randomized controlled clinical trial of a geriatric consultation team. JAMA. 1987;2572313- 2317
Link to Article
Covinsky  KEPalmer  RMKresevic  DM  et al.  Improving functional outcomes in older patients: lessons from an acute care for elders unit. Jt Comm J Qual Improv. 1998;2463- 76
Landefeld  CSPalmer  RMKresevic  DMFortinsky  RHKowal  J A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;3321338- 1344
Link to Article
Palmer  RMLandefeld  CSKresevic  DKowal  J A medical unit for the acute care of the elderly. J Am Geriatr Soc. 1994;42545- 552
Stuck  AESiu  ALWieland  GDAdams  JRubenstein  LZ Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet. 1993;3421032- 1036
Link to Article
Naylor  MBrooten  DCampbell  R  et al.  Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281613- 620
Link to Article
Naylor  MBrooten  DJones  RLavizzo-Mourey  RMezey  MPauly  M Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. Ann Intern Med. 1994;120999- 1006
Link to Article
Bates  DWLeape  LLCullen  DJ  et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;2801311- 1316
Link to Article
Schiff  GDRucker  TD Computerized prescribing: building the electronic infrastructure for better medication usage. JAMA. 1998;2791024- 1029
Link to Article
Monane  MMatthias  DMNagle  BAKelly  MA Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist, and computer. JAMA. 1998;2801249- 1252
Link to Article
Beers  MH Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med. 1997;1571531- 1536
Link to Article
Rochon  PAGurwitz  JH Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;3151096- 1099
Link to Article
McDowell  JAMion  LCLydon  TJInouye  SK A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46700- 705
Hsia  DERubenstein  LZChoy  GS The benefits of in-home pharmacy evaluation for older persons. J Am Geriatr Soc. 1997;45211- 214
Leape  LLCullen  DJClapp  MD  et al.  Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282267- 270
Link to Article
Skolnick  AA FDA sets geriatric drug use labeling deadlines. JAMA. 1997;2781302
Link to Article
Tinetti  MEBaker  DIMcAvay  G  et al.  A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331821- 827
Link to Article
Province  MAHadley  ECHornbrook  MC  et al.  The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials: frailty and injuries: cooperative studies of intervention techniques. JAMA. 1995;2731341- 1347
Link to Article
Close  JEllis  MHooper  RGlucksman  EJackson  SSwift  C Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet. 1999;35393- 97
Link to Article
Rizzo  JABaker  DIMcAvay  GTinetti  ME The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Med Care. 1996;34954- 969
Link to Article
Dyer  CAEWatkins  CLGould  CRowe  J Risk-factor assessment for falls: from a written checklist to the penless clinic. Age Ageing. 1998;27569- 572
Link to Article
Hanson  LCWeber  DJRutala  WA Risk factors for nosocomial pneumonia in the elderly. Am J Med. 1992;92161- 166
Link to Article
Saviteer  SMSamsa  GPRutala  WA Nosocomial infections in the elderly: increased risk per hospital day. Am J Med. 1988;84661- 666
Link to Article
Moody  BLFanale  JEThompson  MVaillancourt  DSymonds  GBonasoro  C Impact of staff education on pressure sore development in elderly hospitalized patients. Arch Intern Med. 1988;1482241- 2243
Link to Article
Bergstrom  NI Strategies for preventing pressure ulcers. Clin Geriatr Med. 1997;13437- 454
Marcantonio  ERGoldman  LMangione  CM  et al.  A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994;271134- 139
Link to Article
Fisher  BWFlowerdew  G A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery. J Am Geriatr Soc. 1995;43175- 178
Muravchick  S Geroanesthesia: Principles for Management of the Elderly  St Louis, Mo Mosby–Year Book Inc1997;
Raja  SNHaythornthwaite  JA Anesthetic management of the elderly. Anesthesiology. 1999;91901- 911
Link to Article
Egbert  AMParks  LHShort  LMBurnett  ML Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men. Arch Intern Med. 1990;1501897- 1903
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 100

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

The Rational Clinical Examination
Case Resolution

The Rational Clinical Examination
Clinical Scenarios