Nursing home patients often receive more drugs than needed. Drug incompatibilities frequently are found, and PRN orders are apt to be overused. Regulatory agencies require periodic physician review in the hope of eliminating these loose prescribing habits. A study was made of the drugs prescribed for 98 patients in a proprietary nursing home. The principal findings were that PRN orders can indeed be inappropriate and indiscriminately followed, and that the multiplicity of drugs often prescribed can lead to drug incompatibilities and to additional illness of the patient. Concern is expressed about the medication review process currently in vogue in nursing homes.
The cost of discarded drugs at a level-III nursing home was calculated for a four-year period. A significant percentage of the cost seemed to be the result of poor prescribing practices. Prescriptions for antibiotics and for psychotropic drugs (particularly PRN orders) are discussed in some detail. Medication policies were developed to improve physicians' prescribing habits in order to reduce these costs without jeopardizing the quality of care.
Evaluation of the quality of care that a nursing home patient receives is difficult and requires physician participation as well as the participation of specially trained nursing personnel. A form of limited medical audit is suggested to aid in such evaluation. In the proprietary nursing home studied by the authors, the quality of care was not being effectively assessed by the survey process then employed. In addition to other factors, emphasis is now placed on the avoidance of additional costs or extra paper work in the process of determining the quality of care.
The notes written by nurses in a level-III nursing home were reviewed in detail. They were found to be neither pertinent nor meaningful in most cases. The daily writing of these notes required a large percentage of the nurses' time but they were seldom, if ever, read by physicians. An alternate system of writing notes on a weekly basis is suggested.
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