Medication Errors in Pennsylvania Nursing Homes

What the errors look like

• Missed doses. The most common by far, and often a staffing consequence. Missed anticoagulants, insulin, cardiac and seizure medications carry serious risk.
• Wrong drug or wrong resident. More likely where agency staff do not know residents.
• Wrong dose, including transcription errors after a hospital discharge, which is a recognized high risk moment.
• Failure to monitor. Some medications require bloods, including anticoagulants and certain psychiatric drugs. Not doing the tests is an error even where the doses were given.
• Failure to recognize an adverse reaction, or to act on one.

Chemical restraint

Antipsychotic medication given to sedate a resident for staff convenience, rather than to treat a diagnosed condition, is a recognized and regulated problem. Federal and state requirements govern informed consent, appropriate indication, monitoring, and attempts at dose reduction.

The signs families notice are a resident suddenly sleepy, unresponsive or slumped, a new diagnosis appearing to justify a drug, or a medication started with nobody having discussed it.

Ask directly: what was started, when, who ordered it, what the indication was, and whether consent was obtained. Then check that answer against the record.

The medication administration record

The MAR is the central document. It shows each medication, each scheduled time, and whether it was given, refused or omitted, usually with a signature or initials.

Compare it against the physician orders. Discrepancies between what was ordered and what the MAR shows are objective, and blocks of initials completed in identical handwriting for a whole shift are a well recognized issue.

What to request

The medication administration record for the relevant period, physician orders and any changes, pharmacy records, the consultant pharmacist’s reviews, laboratory results where monitoring was required, and incident reports relating to medication.