~ Return to:  Links to Topics

~ Return to Home Page:


    The likelihood of medication errors in the nursing home is well recognized within the medical field.  In response to the certainty of errors, the state inspectors must determine the number of medication errors prevalent in a nursing home as part of the annual survey or a complaint investigations involving medications.  There are acceptable percentages and severity of errors in the daily dispensing of medications to residents under Medicare and Medicaid regulations but an excessive number of such errors lead to the facility being cited and required to develop and fulfill a plan of correction.

    The very fact that there is an acceptable level of errors would suggest a high probability that drug errors will not be eliminated in the current system of dispensing medications making all nursing home residents at risk for minor errors and periodically to significant, possibly life threatening situations.

                                                                           PAGE CONTENTS

                            ∆  Medication errors.

                Administering medications.

                ∆  Acceptable medication error rate.

                ∆  Examples of medication errors.

                ∆  Frequency of errors and possible causes.

                ∆  Significant medication errors.

                ∆  Significant and nonsignificant errors.

                ∆  Checklist for dispensing medication

                ∆  Staff medication malpractice.

∆  Medication errors.

    The problems of errors in ordering, recording, storing, accounting for, and dispensing medications is recognized by Federal regulators and addressed by regulation  §483.25(m) Medication errors.

    The regulation requires the facility to ensure that--

       (1.) It is free of medication error rates of 5 percent or greater; and

       (2.)  Residents are free of any significant medication errors.

    A medication error is the observed preparation or administration of drugs or biologicals which is not in accordance with:

   1. Physician’s orders;

   2. Manufacturer’s specifications regarding the preparation and administration of the drug or biological;

   3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.

∆  Administering medications.

    Most medications are administered to residents in the “med pass”.  This process of dispensing medications as ordered is usually done from a cart going from resident to resident following a clearly defined schedule.  The med pass is most often done by a nurse but may be conducted by an unlicensed person if State law permits it being done under the general supervision of a licensed nurse.  The procedures for the administration of medications must be clearly defined by the nursing home in written procedures.

    The med pass can take many hours to dispense the medications plus the necessary time to manage the acquisition of drugs, organize storage, and to complete the documentation related to dispensing, controlling and storing of medications. The nurse assigned these tasks will spend a significant amount of time on medication related matters taking them away from other direct care tasks.

  ∆  Acceptable medication error rate.

    A error rate of 5% or greater, including both significant and nonsignificant medication errors, will result in a deficiency citation by a State inspection team.  Any errors may be brought to the facility’s attention but less than 5% will be treated as acceptable.  That rate is employed to indicate the facility may have systemic problems with its drug management and dispensing system.

    The percentage of errors is determined with the numerator in the ratio being the total number of errors the survey team observes, both significant and nonsignificant. The denominator is called opportunities for errors and includes all the doses the survey team observed being administered plus the doses ordered but not administered.  The error rate must be 5% or greater for the facility to be cited.

  ∆  Examples of medication errors.

    The following situations in drug administration may be considered medication errors:

    • Failure  to “Shake Well”: The failure to shake a drug product that is labeled “shake well.” This may lead to an under dose or over dose depending on the drug product and the elapsed time since the last “shake.” Some drugs, for example dilantin, are more critical to achieve correct dosage delivery than others.

    • Insulin Suspensions: Also included under this category is the failure to “mix” the suspension without creating air bubbles. Some individuals “roll” the insulin suspension to mix it without creating air bubbles. Any motion used is acceptable so long as the suspension is mixed and does not have air bubbles in it prior to the administration.

  • Crushing Medications that should not be Crushed: Crushing tablets or capsules that the manufacturer states “do not crush.”

    •  Adequate Fluids with Medications: The administration of medications without adequate fluid when the manufacturer specifies that adequate fluids be taken with the medication is an error.

    •  Medications that Must be Taken with Food or Antacids: The administration of medications without food or antacids when the manufacturer specifies that food or antacids be taken with or before the medication is considered a medication error.

    Medications Instilled into the Eye: The administration of eye drops without achieving the following critical objectives:

    o Eye Contact: The eye drop, but not the dropper, must make full contact with the conjunctival sac and then be washed over the eye when the resident closes the eyelid; and

    o Sufficient Contact Time: The eye drop must contact the eye for a sufficient period of time before the next eye drop is instilled. The time for optimal eye drop absorption is approximately 3 to 5 minutes.

    • Allowing Resident to Swallow Sublingual Tablets: If the resident persists in swallowing a sublingual tablet such as nitroglycerin despite efforts to train otherwise, the facility should endeavor to seek an alternative dosage form for this drug.

    • Medication Administered Via Metered Dose Inhalers (MDI): The use of MDI in other than the following ways including the use of MDI by the resident. This is an error if the person administering the drug did not do all the following:

    o Shake the container well;

    o Position the inhaler in front of or in the resident’s mouth; and

    o If more than one puff is required, whether the same medication or a different medication,

        wait approximately a minute between puffs.

    If the person administering the drug follows all the procedures described above and there is a failure to administer the medication because the resident can’t cooperate, for example, a resident with dementia may not understand the procedure, this should not be called a medication error. The facility should assess the resident’s circumstance, and possibly attempt other dosage forms such as oral dosage forms or nebulizers.

  ∆  Frequency of errors and possible causes.

    A 2007-08 study in North Carolina by the Medication Error Quality Initiative identified the most frequent medication errors and the possible causes of those errors.  Those findings were:


                • Dose Omission

                • Overdose/multiple Dose

                • Under Dose

                • Wrong Product Strength

                • Expired Order

                • Wrong Documentation

                • Wrong Product

                • Wrong Time

                • Wrong Patient

                • Wrong Duration

                • Monitoring Error

                • Lab work Error

                • Wrong Technique

                • Wrong Form of Product

                • Expired Product

                • Wrong Rate of Administration

                • Wrong Route

Possible Causes

                • Basic Human Error

                • Transcription Error

                • Frequent Distractions/Care Changes

                • Poor Communication

                • Pharmacy Dispensing

                • Medication Unavailable

                • Medication Name Confusion

                • Following Policies & Procedures

                • Too Much Workload/Overtime

                • Shift Change

                • Product Labeling

                • Pharmacy Delivered Wrong Medication

                • Packaging Design

                • Inadequate Information

                • Improper Training

                • Illegible Handwriting

∆  Significant and nonsignificant errors.

    A significant error is one which causes the resident discomfort or jeopardizes his or her health and safety. Discomfort may be a subjective or relative term used in different ways depending on the individual situation.

    For example, constipation that is unrelieved by an ordered laxative that is omitted for one day may be slightly uncomfortable or perhaps not uncomfortable at all. When the constipation persists for greater than three days, the constipation may be more significant causing obstruction or fecal impaction jeopardizing the resident’s health and safety.

    The relative significance of medication errors is a matter of professional judgment. The three general guidelines below are followed in determining whether a medication error is significant or not.  They are:

    Resident Condition - The resident’s condition is an important factor to take into consideration. For example, a fluid pill erroneously administered to a dehydrated resident may have serious consequences, but if administered to a resident with a normal fluid balance may not. If the resident’s condition requires rigid control, a single missed or wrong dose can be highly significant.

    Drug Category - If the drug is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especially important with a drug that has a Narrow Therapeutic Index(NTI) such as a medication in which the therapeutic dose is very close to the toxic dose.

    Frequency of Error - If an error is occurring with any frequency, there is more reason to classify the error as significant. For example, if a resident’s drug was omitted several times, as verified by reconciling the number of tablets delivered with the number administered, classifying that error as significant would be more in order. This conclusion should be considered in concert with the resident’s condition and the drug category.

  ∆  Checklist for dispensing medications.

    The  med pass is complicated and has the potential to produce most medications errors.  A widely published checklist of ten rights focuses on the important steps to administering medications to residents under effective and safe circumstances.  When followed in a med pass, the guidelines can minimize errors and assure the medications are able to provide the desired results.  Those guidelines are:

   1. Right Medication - The nurse should be sure the medication to be administered is that ordered by the physician and appropriate to the resident’s medical condition.

    2. Right Dosage - The nurse should assure the dosage ordered is appropriate to the resident and their physical and medical condition.

    3. Right Patient - New patients, those with similar names, and new employees can lead to the wrong person getting the medications of others so photo, armband, and self identification by the resident are necessary each time medication is dispensed.

    4. Right Manner and Route - Crushing pills to be hidden in food should not be done with delayed absorption medication and someone vomiting may need oral medication administered in another approved form and/or route.

    5. Right Time - Keeping a medication at the same level in the body may require adhering to a tight schedule of dispensation.

  6. Right Documentation - An accurate record of the medication taken by the resident is important so the dispensing nurse should complete the necessary record keeping before moving on to the next resident.

    7. Right Assessment - An immediate condition, such as blood pressure, may determine if a medication decreasing blood pressure is to be given without harm to the resident.

    8. Right Education - The patient should know why they are getting the medication and effects they should expect, food or beverages to be avoided or encouraged, and how to report any undesirable effects.

    9. Right Evaluation - The resident should be observed to assess the outcome of the medication.  Is the drug having the positive effect expected?

    10. Right to Refuse Medication - The right to refuse medication should be respected with the nurse determining why the refusal and inform the physician and care planning team of the refusal for medication adjustments that will address the medical concern.

  ∆  Staff medication malpractice.

    Staff actions or negligence in dispensing medications can be a form of error or malpractice that results in detrimental consequences to residents.  They include:

    •Ignoring medication orders - An employee who purposefully ignores the details of the nursing home’s dispensing procedures or guidelines is committing malpractice.  There are instances of nursing staff choosing to change the dose, discontinue medication, add an unordered medication, or make other medication changes on their own. The result can be the resident not getting the full benefit of the drug therapy ordered or being exposed to potentially harmful conditions.

    •Diverting medications - Diverting is another way of saying stealing medications.  Sooner or later all nursing homes must deal with an employee diverting residents’ drugs for their own use.  As within any career field, nursing will have persons who become addicted and support that addiction any way they can.  The large supply of drugs in nursing homes can be a tempting opportunity.

    •Poor medications management - The failure to renew or maintain a supply of the ordered medications will leave the resident without the required doses.  The poor organization and disorderly maintenance of the medications cart and storage room discourages accounting for and the immediate availability of medications that may be in stock but not where staff can find them.

  1. Medication borrowing - With defective medications management and the rush to complete the med pass, a nurse may have a missing drug due to poor organization, the failure to resupply the medication, or because the needed dose has been borrowed for another resident.  Faced with the pressure to complete the dispensing process, this nurse may resort to borrowing the medication from yet another resident. The effect of borrowing, poor record keeping, and unordered stock destroys organization in the medications supply process, leads to missing doses for some residents, and can hide the diversion of drugs by an employee.


For more information on Medications see:

    The webpage Medication in the Nursing Home on this site by clicking HERE.

    The webpage Pharmacy Services in the Nursing Home can be accessed by clicking HERE.

    The webpage Medications of Concern in the Nursing Home can be accessed by clicking


   More information on medication errors from Appendix PP,  §483.25(m) Medication Errors can be found at:

    End Note: The majority of this section is edited material from Medicare/Medicaid regulation Appendix PP,  §483.25(m) Medication Errors.  The order of presentation for some material has been changed, information not supporting an understanding of medication errors in the nursing home was deleted, and wording and organizational changes were made to create an easier to read document.

* * * *

Return to:  Links to Topics                  Return to Home Page:

Copyright © 2013 by Eric L. Brady, All Rights Reserved