What is a Medication Error?

Over 80% of assisted living residents require assistance with medications, and research suggests that error rates could be as high as 35%. This stresses the importance of monitoring medication errors in your own community.

For the next few weeks Tuesday Tip will be diving deeper into the monitoring and management of medication errors, starting this week with defining what constitutes a “medication error.” In order to effectively monitor-and hopefully reduce-medication errors, everyone in your community must be on the same page regarding what a medication error is.

There are a few approaches to this. One definition is that a medication error is any violation of the “six rights.” Under this definition, an error would include:

  • Giving a medication to the wrong resident
  • Giving the wrong medication
  • Giving the wrong dose
  • Giving a medication at the wrong time
  • Giving a medication by the wrong route, and
  • Not completing the correct documentation

The National Coordinating Council for Medication Error Reporting and Prevention has a more broad definition:

“A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”

It is also prudent to review your state assisted living regulation for a definition of medication errors. Whatever definition you choose to work from, the key point is to have a clear definition of medication errors in your community that is understood by all appropriate staff members.

Next week we will explore medication error reporting.

5 Responses to “What is a Medication Error?”

  1. My question is concerning medication assistance. Is it permissable to use weekly medication boxes in an RCFE setting if the medication tech fills the boxes once a week and each medication assistance by a caregiver is double-checked for the 6 rights?

  2. Hello Brooke. Unfortunately, no, your med tech cannot prefill a weekly pill box for a resident. Section 87465 of the RCFE evaluator manual states that medications can be prefilled for no more than 24-hours in advance: http://ccld.ca.gov/res/pdf/RCFE.pdf

  3. Is a med/tech able to pour for the 24 hour period and then have other aides dispense, or does another med tech have to depense???

  4. Is signing off on med in the MAR ahead. Of scheduled. Time a med. Error med given at correct time ?

  5. In CA CCL guidelines, are verbal orders with clear compliant documentation (name, date, time of whom spoken to, etc) allowable? Here’s what happened to me: I received an verbal order from an MD to Hold a nitroglycerin medication and I labeled the bottle appropriately and documented in client’s chart per guidelines. No policy about “hold” for meds at our facility.

    However, one month later, an emergent incident happened wherein the client had chest pain wanted nitro medication and was given by another staff. No release or reinstatement of nitro hold was received or documented at the time given–only my documentation of verbal order to hold from MD. Suffice to say nitro was given and later found out client chest pain NOT related to cardiac issues.

    Again, are verbal orders allowable? Was this an episode of med error? Please let me know as I want to perform safe practice for my clients in regards to medication. Thanks

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