can have devastating effects to nursing home residents. Proper management of high risk medications
represents a serious challenge for nursing homes, and merits close attention by top management and
staff throughout the facility. We are very concerned about the prevalence of adverse events
involving such medications.
• Focused Survey on Medication Safety Systems and Adverse Drug Event Trigger Tool - The Centers
for Medicare & Medicaid Services (CMS) has begun pilot testing a Focused Survey on Medication
Safety Systems to look at nursing home systems around high risk and problem-prone medications using
an Adverse Drug Event Trigger Tool.
The CMS is making the draft tool available to assist surveyors in investigating medication related
adverse events and to nursing home providers as a risk management tool.