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Preventing Medication

Errors in Long-Term Care

Ilene Warner-Maron
Institute for Continuing Education and Research
(ICER) at the Philadelphia College of
Osteopathic Medicine (PCOM)
Goals of This Program
 Using data collected from Pennsylvania
Department of Health surveys 2009-
◦ Identify 3 factors that increase the risk of
medication errors in long-term care
◦ Identify 5 issues most commonly cited with
regard to medication errors
◦ Identify 5 interventions to decrease the
incidence of these errors
How Long Does it Take for a
Nurse to Administer 9:00 a.m.
medications in your facility?
Defining Medication Errors
 An error occurs when the preparation or
administration of a drug is not done in
accordance with:
◦ Physician’s orders
◦ Manufacturer’s specifications
◦ Accepted professional standards and
principles (by the author of the prescription,
the dispensing pharmacist or the
administrating nurse)
Physician/NP/PA-C Related-Errors
 Handwriting leading to transcription errors
 Lack of specificity regarding diagnosis, duration of
treatment, frequency of administration
 EMR related errors: wrong chart, wrong dose
 Failure to review other medications and allergies
before prescribing additional medications
 Failing to identify the symptoms the new medication
is treating are due to adverse drug reactions from
medications already prescribed
 Lack of physician-physician handoff communication
during transitions of care
 Covering physicians order medications for residents
whom they know very little
“Do No Harm” has changed to
“Do Something”
Pharmacy-Related Errors
 Delivery issues
 Expired medications in E-box, refrigerator
 Dispensing errors
◦ Medication
◦ Dose
 Failure to identify issues:
◦ Laboratory monitoring
◦ Drug-drug interactions
◦ Allergies
◦ Duplicate categories of medications
Nursing-Related Issues
 Failure to follow
◦ Right medication, dosage, resident, route, time
 Failure to assess vital signs
 Failure to monitor laboratory markers for
medications with narrow therapeutic index
 Failure to assess the resident’s condition
before administering the medication
 Dose omissions, “holds,” recaps, crushing
 Friday at 5:00 admissions
 24-hour chart checks “done”
Administrative-Related Issues
 Frequent Distractions/Care Changes
 Communication between disciplines
 Failure to identify medication diversion, re-ordering
issues, multiple STAT orders, restocking E-box,
borrowing from resident to resident
 Inadequate attention to the role of the nurse
administering medications
 Lack of support/resources/supervision
 Contract with pharmacy provider does not include
requirement for medication pass observations, in-
service education or consultations for residents
with frequent falls
Federal Regulations
 42 C.F.R. section 483.25(m):
◦ The facility must ensure that
 1. It is free of medication error rates of 5 percent or
greater and
 2. Residents are free of any SIGNIFICANT medication

The error rate is determined by N/D where the

numerator is the total number of errors the survey
team observes (significant and insignificant) over the
denominator which is the total number of opportunities
for error including all the doses of all the medications
the survey team observed PLUS the doses that were
ordered but not administered
Additional CMS Clarifications:
Enteral Feeding Tubes
 May also involve F322 if:
◦ Placement of tube is not verified before administration of
◦ If residents on fluid restriction receive too many fluids
with medications as well as flushes
◦ If each medication is not administered separately and
flushed before and after administration (unless a physician
specifies flushes should be limited due to fluid balance
◦ F425 pharmacy services may also be cited if there are
inadequate policies as well as F520 for QAA for quality
assurance oversight of policies
Failure to flush before and in between medications
is considered a single medication error
Additional CMS Clarifications: MDI
 If more that one puff is required, whether it
is from the same or different medications,
there is a 1 minute wait between puffs
except for Albuterol and other short-acting
agents where 15-30 seconds is acceptable
 Surveyors are citing facilities for the failure
to have the resident rinse after steroid
 Surveyors have been citing facilities regarding
the ORDER that MDIs are given:
◦ Bronchodilators first
Additional CMS Clarifications: PPIs
 Proton Pump Inhibitors (PPIs) such as Prevacid,
Protonix, Nexium, Aciphex and Prilosec are more
beneficial if given on an empty stomach, 30-60
minutes before meals
 Many older adults are prescribed this category of
medications in the hospital but may not need to
continue the medication in a nursing home or
 The duration and indication for use is required
 May also involve F281 Professional Standards of
Quality, F329 Unnecessary Medications and F425
Pharmacy Services
Additional CMS Clarifications:
Controlled Substances
 Fentanyl (Duragesic) patches should be folded
upon itself (sticky sides together) then placed in
the sharps container with surveillance to prevent
diversion or accidental exposure
 Timely identification and removal of medications
from the current supply
 Identification of storage method for medications
awaiting final disposition
 Documentation by 2 nurses of actual destruction
consistent with state and federal
 Additional F309 QofCare; F425 Pharmacy; F431
Controlled substances; F514 Clinical records;
F520 QAA
Significant versus Insignificant Error
 Significant errors cause discomfort or
pain and jeopardize health and safety and
are dependent upon:
◦ The resident’s underlying condition such
as giving one dose of Lasix to a resident who
is dehydrated
◦ The drug category, particularly medications
with NTI
◦ The frequency of the error including
repeated omissions, failure to observe “holds”
General Medication Errors Seen in
the US Long-Term Care Facilities
 Failure to shake  Giving meds before
medications as meals instead of with
required by the label meals
 Mixing, rolling, creating  Giving meds with
air bubbles in insulin meals instead of before
 Crushing medications  Failing to wait 3-5
on the no crush list minutes between eye
 Incorrect amount or drops
type of fluids given  Failing to administered
MDI in the correct
order and with
sufficient time
between puffs
Part D-Related Errors
 Part D providers may require a
substitution of a prescribed medication
using a different formulary, adding further
steps to the process of administration
 Part D providers may substitute
extended-release medications, requiring
the use of shorting acting medications to
be administered more frequently
Tracking and Reporting Errors
 A Pennsylvania cautionary tale of Coumadin
 Define categories of errors (prescribing,
dispensing, administration, monitoring,
 Develop a simple medication error reporting
form and process for investigation
 Increase education and knowledge of all
types of errors
 Conduct root cause analysis (RCA) as many
issues are multi-factorial
Medication Errors PA DOH
Citations 2009-2012
 Methodology: surveys of all types
reviewed for four years, noting citations
for any type of medication error F332
 Total number of surveys reviewed: 16, 125
 Total number of citations for all counties
in PA: 738
Citations by County 2009-2012
County Number of Citations
Allegheny 78
Lycoming 38
Montgomery 32
Washington 30
Northampton 29
Lancaster 28
Luzerne 25
Mifflin 24
Westmoreland 24
Northumberland 23
Mercer 22
Lebanon 21
Schuylkill 21
Types of Medication Errors 2009-
Type of Error Number of Percent of
Citations Citations
Wrong dose, calculation issues, 94 12.74%
spilled full dose, wrong strength
Crushed inappropriately 82 11.11%
Not administered due to 71 9.62%
unavailability, missing
Wrong time 60 8.13%
Should have been given with food 59 7.99%
or milk
Should have been given in a fasting 47 6.37%
MDI administered without rinsing 35 4.74%
Pharmacy delivery issues 27 3.66%
MDI administered too closely 24 3.25%
Other Common PA DOH Citations
 No/expired order  MAR does not match
 Infection control Controlled Drug log
violations  E-box issues
 Insufficient diluent  Therapeutic
 SSI timing issues Interchange error
 Eye drop  Allergies
technique/time  Acetaminophen dose
between drops exceeded
 Transcription errors  Cardiac medications
 Recap errors not held despite vital
signs outside of
Other Common PA DOH Citations
 Failure to report significant  Failure to remove one patch
medication errors to DOH before placing another
 Anticoagulant doses not  No order for self-
altered in accordance with administration
PT/INR  Pre-signing medications
 LOA medications given  Medication schedule not
without directions for family changed when dialysis
 Policy failures schedule changed
 Anemia medications given  Inadequate resident
without monitoring instruction
laboratory results or  No gradual dose reductions
obtaining parameters for psychotropics
 Incorrect medications from
Medication Caveats
 SSI  Cathartics/stimulants
 MDI requiring 8 ounces of
 Thyroid preparations water
 Multiple forms of  Inhalers followed by
acetaminophen pills
 Policies to cover NTG  Labeling of OTC and
in case of angina supplements
 Medications that are  Pre-authorized
every other day, medication delays
weekly or monthly  Measurement of
Medication Caveats
 OD, OS, OU artificial  Nurse unaware of the
tears reason a medication
 Lidoderm over area of was administered
pain  Nurse unaware of the
 Reading x 3 not done differences in onset,
 Physician not informed peak and duration of
when medications are insulins administered
unavailable  Hospitalization for
 Delays in obtaining residents administered
narcotics for new wrong drugs, allergies
 Split halls for 8 and 9 a.m. medications to
allow for 3 hours of medication
 Separate pharmacy provider from pharmacy
 Ensure monthly medication pass by
pharmacy to desensitize nurses to
 Reviews to decrease the number of
medications in total and those administered
at 9 a.m.
 Replace SSI with standard dosing for the individual
 Anticoagulant flow sheets
 Checking the 24-hour chart check
 Resources for Do Not Crush (ER, XL, LA, SR and
other suffixes
 In-services for the use of MDIs
 Observations of nurses during med passes
 Decreasing interruptions for nurses
 Increased use of pharmacy consulting services for
residents with falls and other potential issues
related to medications
 Particular attention to “hold” medications
and when to resume them
 LOA instructions for medication use
 BP in 2 positions at least weekly for
residents on one or more antihypertensive
 Understanding and disseminating information
about policies, medication errors while
maintaining an atmosphere where self-
reporting errors is supported/expected
 48 hour oversight and multiple reviews of all
new admissions

 Issue: A resident was admitted for

rehabilitation following a hospitalization for
newly diagnosed Stage IV breast cancer. The
oral chemotherapy agent was not
administered during the entire 3 week
RCA for Missed Chemotherapy
 Intended Process Flow
 Missteps in Process
 Human Factors
 Equipment Failure
 Environmental Factors
 Organizational Factors
 Staff Competence
 Staffing
 Information Readily Available
 Communication Issues
 Education
 Technology
American Society of Consultant Pharmacists (ASCP) Guidelines on Preventing
Medication Errors in Pharmacies and Long-Term Care Facilities Through
Reporting and Evaluation, 1997.
Aronow, Wilbert S. Multiple Blood Pressure Medications and Mortality Among
Elderly Individuals. Journal of the American Medical Association (JAMA) 2015;
313;(13): 13642-4.
Brady, Eric L. Medication Errors in the Nursing Home.
Mixon, Amanda S et al. Characteristics Associated with Postdischarge Medication
Errors. Mayo Clinic Proceedings 2014;89(8):1042-1051
Munley, Evvie. CMS Memo Clarifies Nursing Home Survey Guidance for
Medication Errors and Pharmacy Services. LeadingAge November 7, 2012.
Stefanacci, RG and Spivack, BS. Preventing Medication Errors. Annals of Long-
Term Care 2006; 14(10).

Many thanks to my former colleague at St. Joseph’s University, Reecha Sharma,

MD, for her assistance with the analysis of DOH data.