Warfarin, insulin, oral antiplatelet agents, and oral hypoglycemics were the drugs most often behind nearly 100,000 emergency hospitalizations for adverse drug events among older Americans between 2007 and 2009. Every one of them is a drug somebody needed.
That is the part of medication safety in long-term care that gets least attention. The risk in an older resident’s regimen usually comes from a drug that was right at some point, kept going after the reason for it faded, and stopped being watched closely. Catching those is the work Michal Voldiner treats as central at Ultimate Care Rx, her long-term care pharmacy in Burbank, which serves communities across Los Angeles County.
Table of Contents
Why Stopping a Drug Is Harder Than Starting One
A new prescription has an obvious author. Someone examined a resident, reached a conclusion, and wrote an order.
Stopping doesn’t have that momentum behind it. The drug already sits on the list with an indication on record, a prescriber who chose it, and a resident accustomed to taking it. Removing it means someone has to go back through a history that may span several providers and years, decide the original reason no longer holds, and then persuade the physician who owns the order. The default answer at every one of those steps is to leave things alone, and that’s how a regimen only ever grows.
Long-term care makes the arithmetic worse. Residents arrive with lists assembled elsewhere, from hospital stays and specialist visits and primary care, and no single prescriber has ever seen the whole thing at once.
Federal Rules Already Have a Name for the Problem
The people who wrote the regulations governing nursing communities understood this, and they built a category for it.
Under 42 CFR 483.45, every resident’s drug regimen has to be reviewed at least once a month by a licensed pharmacist, and each resident’s regimen must be free of what the rule calls unnecessary drugs. The definition is specific. A drug is unnecessary if it is used in excessive dose, including duplicate therapy; for excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences that indicate the dose should be reduced or discontinued.
Read that list closely and it describes a drug nobody prescribed in error. Excessive duration is a correct prescription that outlived its purpose. Inadequate monitoring is a drug that still belongs but whose effects stopped being tracked. Those are the two failure modes behind the hospitalizations in the federal count, and the regulation puts a licensed pharmacist in front of them once a month by law.
The monthly review isn’t a filing exercise. When a pharmacist finds an irregularity, it goes to the attending physician, the medical director, and the director of nursing in a written report naming the resident, the drug, and the problem, and the physician has to document what they did about it. Surveyors treat weak monitoring as a serious finding: failure to monitor can draw a harm-level citation or higher under the tag covering unnecessary drugs.
What the Evidence Shows About Deprescribing in Long-Term Care
The honest version of the research is narrower than the enthusiasm around it, and worth stating plainly.
AHRQ’s February 2024 review of deprescribing found that most studies reduced medication counts, potentially inappropriate medications, or both, and that few adverse drug withdrawal events resulted from the interventions. Taking drugs away, done deliberately, works, and it rarely backfires. The same review found most studies showed no reduction in falls, and noted that many interventions reducing polypharmacy have not yet been consistently linked to improved clinical outcomes.
What holds up, then, is a narrower claim: a shorter, better-monitored medication list strips out risk factors for the events that put older residents in a hospital bed, and stripping them out costs the resident almost nothing. A federal review of skilled nursing care put numbers on the other side of that trade: 22% of Medicare beneficiaries experienced an adverse event during their stay, adverse drug events were the most common kind, reviewers rated roughly half of them preventable, and more than half of the residents affected ended up hospitalized. Those are the events the monthly review is aimed at.
Michal Voldiner’s Standard for the Stop Order
What the regulation cannot supply is the willingness to make the call.
A monthly review can be run as documentation or as clinical work, and the difference shows up in what a pharmacist does after finding something. Her pharmacists call the prescriber, make the clinical case for a change, and bring a substitute to the conversation instead of a complaint. Some of those conversations end with a dose reduction, some with a drug coming off the list, and some with the prescriber explaining a reason the pharmacy could not see from the chart. All three outcomes are the process working.
Continuity is what makes those calls productive. A pharmacist reviewing the same residents month after month builds a picture no single chart holds: which drug started during a hospital stay two winters ago, which one the resident has quietly disliked, which lab has not been drawn since the dose last changed. That accumulated context turns a regulatory minimum into a running argument on the resident’s behalf, and it is why Voldiner treats the monthly review as clinical work rather than paperwork.
A stopped drug doesn’t leave anything behind that a family can point to. Nobody thanks a pharmacy for a medication a resident came off six months ago, or for the hospital stay that never happened as a result. Michal Voldiner built Ultimate Care Rx around doing it anyway, on the theory that the least visible work in long-term care pharmacy is where the most avoidable harm lives.
