Identifying clinician-reported medication “Failure modes” in the nursing home setting that are amenable to active monitoring

OBJECTIVES: Nursing home residents are at high-risk for preventable harm and medication errors. This study aimed to identify clinician-reported medication safety failure modes in U.S. nursing homes and prioritize those most suitable for informatics-enabled active monitoring interventions. METHODS: We conducted a mixed-methods failure mode and effects analysis. Semi-structured interviews and field observations were conducted with 23 nursing home clinicians (duration 60-90 min). Interview anecdotes were translated into stepwise failure modes and represented as Unified Modeling Language (UML) workflow diagrams. Respondents rated each scenario's perceived seriousness, detectability, and frequency of routine monitoring; these ratings were combined to identify high-priority targets for intervention. RESULTS: Fourteen failure modes were refined into 10 generalizable clinical scenarios and evaluated via a survey of 61 nursing home healthcare providers from a wide range of sites and roles. Across clinical roles, survey respondents consistently prioritized meclizine/psychotropic co-exposure and diuretic/mobility impairment co-exposure as high-priority scenarios for active monitoring. Scenarios involving psychotropic/CNS-active medications and potential drug-drug interactions were also frequently rated as important and not routinely monitored. CONCLUSIONS: Clinician-derived medication nursing home safety failure modes have been prioritized using multi-stakeholder survey input, yielding a focused set of targets for medication-safety monitoring in nursing homes. IMPLICATIONS: The identified high-priority scenarios can inform the design of automated monitoring tools and pharmacist/nursing workflows. Future work should validate these targets against resident outcomes and evaluate the effectiveness of monitoring interventions.