Types, Prevalence, and Potential Clinical Significance of Medication Administration Errors in Assisted Living

Authors

  • Heather M. Young PhD, GNP,

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • Shelly L. Gray PharmD, MS,

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • Wayne C. McCormick MD, MPH,

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • Suzanne K. Sikma PhD, RN,

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • Susan Reinhard PhD, RN,

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • Linda Johnson Trippett RNC, MSN,

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • Carol Christlieb RN, MSN,

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • Tiffany Allen BS

    1. From the *School of Nursing, Oregon Health and Science University Ashland, OregonSchool of PharmacySchool of Medicine, University of Washington, Seattle, Washington§Nursing Program, University of Washington at Bothell, Bothell, WashingtonAARP Public Policy Institute, Washington, District of Columbia.
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  • This article was presented at the Annual Meeting of the Gerontological Society of America, November 2006, Dallas, Texas.

Address correspondence to Heather M. Young, PhD, GNP, School of Nursing, Oregon Health and Science University, 1250 Siskiyou Blvd., Ashland, OR 97520. E-mail: younghe@ohsu.edu

Abstract

OBJECTIVES: To describe the types and potential clinical significance of medication administration errors in assisted living (AL).

DESIGN: Cross-sectional observational study.

SETTING: This study was conducted in 12 AL settings in three states (Oregon, Washington, and New Jersey).

PARTICIPANTS: Participants included 29 unlicensed assistive personnel and 510 AL residents.

MEASUREMENTS: Medication administration observations, chart review, and determination of rates, types, and potential clinical significance of errors using standardized methodology.

RESULTS: Of 4,866 observations, 1,373 errors were observed (28.2% error rate). Of these, 70.8% were wrong time, 12.9% wrong dose, 11.1% omitted dose, 3.5% extra dose, 1.5% unauthorized drug, and 0.2% wrong drug. Excluding wrong time, the overall error rate dropped to 8.2%. Of the 1,373 errors, three were rated as having potential clinical significance.

CONCLUSION: A high number of daily medications are given in AL. Wrong time accounted for the majority of the errors. The bulk of the medications are low risk and routine; to promote optimal care delivery, clinicians need to focus on high-risk medications and residents with complex health problems.

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