Potentially Harmful Medication Dispenses After a Fall or Hip Fracture: A Mixed Methods Study of a Commonly Used Quality Measure

Published:January 12, 2022DOI:


      High-risk medication dispenses to patients with a prior fall or hip fracture represent a potentially dangerous disease-drug interaction among older adults. The research team quantified the prevalence, identified risk factors, and generated patient and provider insights into high-risk medication dispenses in a large, community-based integrated health system using a commonly used quality measure.


      This was a mixed methods study with a convergent design combining a retrospective cohort study using electronic health record (EHR) data, individual interviews of primary care physicians, and a focus group of patient advisors.


      Of 113,809 patients ≥ 65 years with a fall/fracture in 2009–2015, 35.4% had a potentially harmful medication dispensed after their fall/fracture. Most medications were prescribed by primary care providers. Older age, male gender, and race/ethnicity other than non-Hispanic White were associated with a reduced risk of high-risk medication dispenses. Patients with a pre-fall/fracture medication dispense were substantially more likely to have a post-fall/fracture medication dispense (hazard ratio [HR] = 13.26, 95% confidence interval [CI] = 12.91–13.61). Both patients and providers noted that providers may be unaware of patient falls due to inconsistent assessments and patient reluctance to disclose falls. Providers also noted the lack of a standard location to document falls and limited decision support alerts within the EHR.


      High-risk medication dispenses are common among older patients with a history of falls/fractures. Future interventions should explore improved assessment and documentation of falls, decision support, clinician training strategies, patient educational resources, building trusting patient-clinician relationships to facilitate long-term medication discontinuation among persistent medication users, and a focus on fall prevention.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Joint Commission Journal on Quality and Patient Safety
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. World Health Organization. Falls. Apr 26, 2021. Accessed Jan 19, 2022.

      2. World Health Organization. WHO Global Report on Falls Prevention in Older Age. 2007. Accessed Jan 19, 2022.

      3. Centers for Disease Control and Prevention. Important Facts About Falls. Feb 10, 2017. Accessed Jan 19, 2022.

        • Centers for Disease Control and Prevention
        Deaths from falls among persons aged ≥65 years—United States, 2007–2016.
        MMWR Morb Moral Wkly Rep. 2018 May 11; 67: 509-514
      4. US Census Bureau. 65 and Older Population Grows Rapidly as Baby Boomers Age. Jun 25, 2020. Accessed Jan 19, 2022.

      5. US Census Bureau. An Aging Nation: the Older Population in the United States. Ortman JM, Velkoff VA, Hogan H. May 2014. Accessed Jan 19, 2022.

        • Woolcott JC
        • et al.
        Meta-analysis of the impact of 9 medication classes on falls in elderly persons.
        Arch Intern Med. 2009 Nov 23; 169: 1952-1960
        • Leipzig RM
        • Cumming RG
        • Tinetti ME.
        Drugs and falls in older people: a systematic review and meta-analysis: I. psychotropic drugs.
        J Am Geriatr Soc. 1999; 47: 30-39
        • Thapa PB
        • et al.
        Psychotropic drugs and risk of recurrent falls in ambulatory nursing home residents.
        Am J Epidemiol. 1995 Jul 15; 142: 202-211
        • National Committee for Quality Assurance (NCQA)
        HEDIS 2015: Healthcare Effectiveness Data and Information Set, vol 2.
        NCQA, Washington, DC2015
      6. National Committee for Quality Assurance. HEDIS Measures and Technical Resources Accessed Jan 19, 2022.

        • Pugh MJV
        • et al.
        Exposure to Potentially harmful drug-disease interactions in older community-dwelling veterans based on the Healthcare Effectiveness Data and Information Set quality measure: who is at risk?.
        J Am Geriatr Soc. 2011; 59: 1673-1678
        • Aspinall SL
        • et al.
        Epidemiology of drug-disease interactions in older veteran nursing home residents.
        J Am Geriatr Soc. 2015; 63: 77-84
        • American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
        J Am Geriatr Soc. 2019; 67: 674-694
        • Hanlon JT
        • et al.
        Potential drug–drug and drug–disease interactions in well-functioning community-dwelling older adults.
        J Clin Pharm Ther. 2017; 42: 228-233
        • Koebnick C
        • et al.
        Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data.
        Perm J. 2012; 16: 37-41
        • Rondeau V
        • Mazroui Y
        • Gonzalez JR.
        frailtypack: an R package for the analysis of correlated survival data with frailty models using penalized likelihood estimation or parametrical estimation.
        J Stat Softw. 2012; 47: 1-28
        • Agresti A
        • Coull BA.
        Approximate is better than “exact” for interval estimation of binomial proportions.
        Am Stat. 1998; 52: 119-126
        • Michie S
        • et al.
        Making psychological theory useful for implementing evidence based practice: a consensus approach.
        Qual Saf Health Care. 2005; 14: 26-33
        • Atkins L
        • et al.
        A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems.
        Implement Sci. 2017 Jun 21; 12: 77
        • National Committee for Quality Assurance
        Proposed Changes to Existing Measures for HEDIS® 2020: Use of High-Risk Medications in the Elderly (DAE) and Potentially Harmful Drug-Disease Interactions in the Elderly (DDE).
        2019 (Accessed Jan 19, 2022.)
        • Miller GE
        • et al.
        Determinants of potentially inappropriate medication use among community-dwelling older adults.
        Health Serv Res. 2017; 52: 1534-1549
        • Assari S
        • Bazargan M.
        Race/ethnicity, socioeconomic status, and polypharmacy among older Americans.
        Pharmacy (Basel). 2019 Apr 25; 7: 41
        • Ambrose AF
        • Paul G
        • Hausdorff JM.
        Risk factors for falls among older adults: a review of the literature.
        Maturitas. 2013; 75: 51-61
        • Huang AR
        • et al.
        Medication-related falls in the elderly: causative factors and preventive strategies.
        Drugs Aging. 2012 May 1; 29: 359-376
        • Bloch F
        • et al.
        Psychotropic drugs and falls in the elderly people: updated literature review and meta-analysis.
        J Aging Health. 2011; 23: 329-346
        • Sim JJ
        • et al.
        Low systolic blood pressure from treatment and association with serious falls/syncope.
        Am J Prev Med. 2018; 55: 488-496
      7. Centers for Disease Control and Prevention. STEADI—Older Adult Fall Prevention. Jul 26, 2021. Accessed Jan 19, 2022.

        • Berry SD
        • Kiel DP
        • Colón-Emeric C.
        Hip fractures in older adults in 2019.
        JAMA. 2019 Jun 11; 321: 2231-2232
      8. US Preventive Services Task Force. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement.
        JAMA. 2018 Apr 24; 319: 1696-1704
        • Hahn EE
        • et al.
        Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study.
        J Gen Intern Med. 2021; 36: 3015-3022
        • Steinman MA
        • Landefeld CS.
        Overcoming inertia to improve medication use and deprescribing.
        JAMA. 2018 Nov 13; 320: 1867-1869
        • Munson JC
        • et al.
        Patterns of prescription drug use before and after fragility fracture.
        JAMA Intern Med. 2016 Oct 1; 176: 1531-1538
        • Boyé NDA
        • et al.
        Effectiveness of medication withdrawal in older fallers: results from the Improving Medication Prescribing to reduce Risk Of FALLs (IMPROveFALL) trial.
        Age Ageing. 2017 Jan 10; 46: 142-146
        • Pit SW
        • et al.
        A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial.
        Medical J Aust. 2007 Jul 1; 187: 23-30
        • Christiansen TL
        • et al.
        Patient activation related to fall prevention: a multisite study.
        Jt Comm J Qual Patient Saf. 2020; 46: 129-135
        • Dykes PC
        • et al.
        Pilot testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.
        Jt Comm J Qual Patient Saf. 2017; 43: 403-413
        • Martin P
        • et al.
        Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial.
        JAMA. 2018 Nov 13; 320: 1889-1898
        • Clyne B
        • et al.
        Effectiveness of a multifaceted intervention for potentially inappropriate prescribing in older patients in primary care: a cluster-randomized controlled trial (OPTI-SCRIPT study).
        Ann Fam Med. 2015; 13: 545-553
        • Kitchen SA
        • et al.
        Emergency department-based medication review on outpatient health services utilization: interrupted time series.
        BMC Health Serv Res. 2020 Mar 26; 20: 254
      9. Centers for Medicare & Medicaid Services, Medicare Learning Network. Medicare Wellness Visits. (Updated: Feb 2021.) Accessed Jan 19, 2022.

        • Berry SD
        • Miller RR.
        Falls: epidemiology, pathophysiology, and relationship to fracture.
        Curr Osteoporos Rep. 2008; 6: 149-154
        • Balasubramanian A
        • et al.
        Risk of subsequent fracture after prior fracture among older women.
        Osteoporos Int. 2019; 30: 79-92
        • Danforth KN
        • et al.
        Electronic clinical surveillance to improve outpatient care: diverse applications within an integrated delivery system.
        EGEMS (Wash DC). 2014 Jun 24; 2: 1056
        • Luna DR
        • et al.
        User-centered design improves the usability of drug-drug interaction alerts: experimental comparison of interfaces.
        J Biomed Inform. 2017; 66: 204-213
        • Ancker JS
        • et al.
        Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system.
        BMC Med Inform Decis Mak. 2017 Apr 10; 17: 36
        • Iaboni A
        • Flint AJ.
        The complex interplay of depression and falls in older adults: a clinical review.
        Am J Geriatr Psychiatry. 2013; 21: 484-492