To the Editor.—It was interesting to read the report of the variability of medication levels in nursing home patients by Mooradian et al1 in the April 1989 issue of the Archives. In our 1200-patient extended care nursing home program, based at a county teaching hospital, 2 we also frequently detect unexplained variations in medication levels in individual patients.
I would take issue, however, with the authors' disclaimer that "in institutionalized patients, patient compliance is not an issue." In our system, we have witnessed an alarming increase in the frequency of episodes when medications have not been properly administered to patients. This has been manifested by aggregates of patients with subtherapeutic prothrombin times and undetectable medication levels and episodes of unexplained lack of medication efficacy, in addition to medication errors self-reported by nursing staff.
In the upper midwest, as in other areas of the country, there remains an acute