Most nursing home residents rely on a careful treatment regimen and medication to maintain their health and quality of life. When nursing homes, physicians, nurses, or pharmacists are negligent and allow medication errors to happen, residents can suffer serious harm.
Despite strict federal and California regulations governing the ordering, storage, administration, monitoring, and recording of medications, medication errors in nursing homes are very common.
If you suspect your loved one has been the victim of nursing home abuse or medical malpractice involving medication errors, an experienced California medication error attorney can help.
What Is a Medication Error?
The most widely used definition of a medical error comes from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP):
“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.”
Medication errors can include events that cause harm to the patient, have the potential to cause harm, “near miss” events, and mistakes that do not actually cause harm. These mistakes can happen at any point in the chain of treatment from prescribing and dispensing the drug to administration and monitoring.
California Nursing Home Medication Regulations
California nursing homes or skilled nursing facilities (SNFs) are licensed by the California Department of Public Health. Most are also certified to participate in Medi-Cal and Medicare and must meet California and federal standards. Nursing homes are subject to federal and California care standards and usually Medi-Cal and Medicare standards as well related to medication administration and management.
Title 22 CA Code of Regulations requires skilled nursing facilities to meet many pharmaceutical regulations:
- Maintain a record of every drug ordered, the patient name, drug name and strength, date ordered, date and amount received, and name of the issuing pharmacy for at least one year
- Obtain necessary drugs in a prompt and timely manner
- Dispense, label, store, and administer drugs according to state and federal laws
- Monitor a drug distribution system that includes ordering, dispensing, and administering medication
- Provide consultative and other services by pharmacists to develop, coordinate, supervise, and review pharmaceutical services
- Retain a pharmacist who reviews each patient’s drug regimen at least once a month and prepares appropriate reports. This review should include a review of all drugs ordered, information about the patient’s condition, medication administration records, and if necessary, nurse’s notes, progress reports, and lab results.
- Pharmacists are required to report irregularities in drug regimens and treatment to the resident’s attending physician, facility administrator, and director of nursing. Action must be taken on these reports.
There are also specific long-term care medication administration guidelines under Title 22:
- Medications and treatments may only be administered on the order of someone lawfully authorized
- Medications and treatments must be administered as prescribed
- Vital signs and tests performed during administration of treatments and medications must be performed as required with the results recorded
- Doses cannot be prepared for more than one scheduled administration time
- With few exceptions, all treatments and medications must be administered by a licensed medical or nursing professional
- Medication must be administered as soon as possible and within two hours of preparation and by the person who prepares the doses
- Patient identity must be confirmed prior to administration
- Medication can only be used for the patient for whom it was prescribed
- The dose and time of treatment and medications must be recorded to the patient’s medication record
Here are additional important nursing home regulation requirements.
- Consent. Residents and legal representatives have the right to consent to or refuse treatments and medications. Physicians must obtain consent to change or order medication.
- Pharmacy choice. Residents have the right to choose their own pharmacy with some limitations.
- Unnecessary medication. Federal law prohibits nursing homes from over-prescribing or prescribing unnecessary medications. This includes medications with adverse consequences, without sufficient justification, for an excessive amount of time, or at an excessive dose.
- Restricted medication. Federal law restricts certain drugs. The use of tranquilizers, sedatives, and similar medications can only be used with documented medical need. Antipsychotic drugs should only be used to treat diagnosed, documented mental illness. The facility must attempt to discontinue their use through behavioral intervention and other means if appropriate.
Finally, residents must be free of significant medication errors under Title 42 § 483.45. Medication errors in nursing homes must be kept at or below a rate of 5%.
Causes of Medication Errors & How to Prevent Medication Errors in Nursing Homes
Despite many clear long-term care medication administration guidelines, nursing home medication errors are common. These prescription errors are usually preventable and caused by carelessness, understaffing, and poor management. Here are some of the most common causes of medication errors in nursing homes – and what facilities should do to prevent them.
Improper Administration of Medication
Many medication errors in nursing are related to incorrect drug administration. This includes using the incorrect administration technique, administering the wrong dose, giving medication to the wrong patient, or administering the wrong drug.
Nursing staff have a duty to follow medication instructions and make sure drugs are administered correctly. This means:
- Providing antacids, adequate food, or liquids with medication
- Following protocol when administering medication with enteral nutritional formulas (ENFs)
- Properly mixing, shaking, or rolling medication to prevent air bubbles and ensure the patient does not receive too little or too much medication
- Waiting the correct amount of time between doses of metered dose inhalers (MDIs)
- Not allowing patients to swallow sublingual medication
- Not cutting, slicing, or crushing tablets that must be taken whole
Solutions
- Following the 5 Rights in nursing: Right Patient, Right Time, Right Dose, Right Medication, Right Route
- Barcode medication administration reduces the risk of medications being given to the wrong patient
- The patient’s medication may need to be changed if issues are noticed such as repeatedly swallowing sublingual tablets
Poor Communication
Sadly, many medication mistakes happen due to poor communication between nursing staff, nurse practitioners, physicians, hospitals, and emergency rooms. There are many communication issues that are common in long-term care settings:
- Medical decisions are often made over the phone or based on brief conversations between staff and medical professionals.
- There are usually several covering providers making medical decisions with little knowledge of the patient.
- Transitions between a hospital, emergency room, and the nursing home increase the risk that important treatment information is not passed on properly.
- Poor health information technology infrastructure limits a prescriber’s ability to review important information about the patient and their medical history off-site.
- Inadequate information when medication is ordered including potential interactions, lab test results, multiple medications, and the patient’s medical conditions.
Solutions
There are many ways nursing home facilities can support better communication among staff and care providers:
- Medication reconciliation during transitions in care
- Communication strategies like the BATHE Protocol (Background, Affect, Troubles, Handling, Empathy) and the STICC Protocol (Situation, Task, Intent, Concern, Calibrate)
- Incorporating health information technology for team members to communicate
- Safer Sign Out, a team-based tool that uses structured communication to prevent communication breakdown during handoff
- Training staff in effective communication strategies and vulnerable areas of concern
Dangerous Adverse Effects from Inappropriate Medications
Most nursing home residents take at least one prescription medication, but many have a complex drug regimen with multiple prescriptions. Older adults are already at an increased risk of adverse effects from medications, but this risk increases with multiple drugs. When a medication poses a high risk of adverse reaction or is considered unnecessary, it’s considered an inappropriate medication.
For example, antipsychotics are commonly overprescribed despite research showing they can be dangerous for older adults who are more likely to experience seizures as a result.
Warfarin is one of the most common medications used in nursing homes. It’s used to reduce the rate of stroke associated with atrial fibrillation, but research has questioned the safety and quality of warfarin therapy in long-term care. About 10% of nursing home residents receive warfarin treatment, but less than 50% of time is spent within the therapeutic range.
Preventable medication injuries and near misses are common and about 30% of adverse effects like bleeding are preventable. The most serious, life-threatening, or fatal events, which happen at a rate of 2.5 per 100 resident-months on warfarin, are preventable 60% of the time.
One study of Georgia nursing homes found 46.5% of patients received at least one inappropriate medication based on the Beers criteria and almost 13% of patients had at least one adverse outcome.
Solution
Proper screening for risk factors can reduce the risk of adverse drug events. Effective screening tools like the Screening Tool of Older Person’s inappropriate Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START) help predict adverse medication events and help clinicians review medications that may be inappropriate in older adults. The CMS Adverse Drug Event Trigger Tool helps recognize common, preventable adverse drug events, risk factors, and triggers.
Look-Alike and Sound-Alike Drugs
Look-alike or sound-alike (LASA) medications are easily mistaken for each other and may lead to serious harm if the error is not noticed before it reaches the patient. It’s estimated that LASA errors are involved in 6.2% to 14.7% of all medication error events.
Here are just some examples of prescription drugs in nursing homes with similar names:
- Lovenox and lovastatin
- Lorazepam and alprazolam
- Clonazepam and lorazepam
- Clonazepam and clobazam
- Sulfadiazine and sulfasalazine
- Propranolol and prednisolone
- Carbamazepine and carbimazole
- Amlodipine and atenolol and allopurinol
- Rosuvastatin and rivaroxaban
- Acetaminophen hydrocodone bitartrate and acetaminophen oxycodone hydrochloride
In elderly or frail patients, these errors can cause serious side effects, drug interactions, and even death. For example, atenolol treats angina, hypertension, and heart rhythm disturbances while allopurinol prevents gout and treats kidney stones. Giving a patient with normal blood pressure atenolol by mistake can cause loss of consciousness, an increased risk of falls, and even death.
Solutions
ISMP maintains a List of Confusing Drug Names which can help providers and nursing homes develop safeguards to avoid wrong medication errors. ISMP offers many suggestions for preventing prescription mistakes including
- Purchasing look-alike drugs from different manufacturers
- Verifying the indication matches the patient’s condition and the drug’s intended use
- “Tall man lettering”
- Including brand and generic names with indication on medication administration records (MARs)
- Adopting barcode medication administration
Poor Handwriting
The illegible scrawl of doctors is a common joke, but it’s a problem that can have serious consequences for patients. Research estimates 21% of handwritten prescriptions have at least one error. Even worse, a correctly written prescription can be misread or misinterpreted by pharmacists and hospital workers.
A decade ago, sloppy handwritten prescriptions were responsible for over 7,000 deaths and even more adverse effects every year. These deaths have declined dramatically since the widespread adoption of electronic prescriptions, but handwritten prescriptions are still used by some physicians and facilities.
Solution
Using a computerized provider order entry (CPOE) system. This ensures prescriptions and treatment instructions as well as lab and radiology orders are entered and received electronically to eliminate errors caused by handwriting.
Medication Borrowing
This happens when understaffing and poor medication management collide. During med pass, overwhelmed staff may borrow medication from one patient and give it to another to speed up medication administration. While the intention may be to replace the borrowed medication, busy staff can forget and patients may miss their dose. Medication borrowing is even more dangerous when staff fail to account for or note the borrowed medication which can lead to additional errors.
A 2008 ISMP survey found half of the 1,296 nurses surveyed borrowed drugs when the doses for patients was missing.
Solutions
- Identify and correct reasons for medication borrowing. Facilities should learn why staff borrow meds and take action to improve deficiencies in the system for dispensing medication.
- Staff training and education. Nurses and practitioners should be trained on the serious risks of borrowing meds. Pharmacists should also understand the consequences of delaying order reviews and medication dispensing.
- Identify reasons for missing medications. This may include discontinued drugs still listed on the patient’s record, drugs administered but not noted on the record, and additional doses were used to replace doses that were vomited or dropped.
Other Forms of Nursing Home Negligence & Medical Malpractice
There may be many other reasons for medication errors in assisted living facilities and nursing homes, many of which rise to the level of negligence or malpractice.
- Nursing home understaffing
- Negligent hiring practices
- Inadequate training of nursing staff
- Failure to implement policies to prevent medication errors
- Poor medication management such as inadequate documentation, failing to order correct medications, improper medication storage, or giving expired medications to patients
- Failing to treat a patient’s condition, transfer them for care, or make a referral when needed
- Ignoring the stated medical concerns of a patient
- Ignoring medication orders by discontinuing medication, adding medication that was not ordered, or changing dosage
- Failing to provide prescribed medication
- Failing to check for drug interactions
- Failing to monitor patients after administering medication
- Delegating medication administration to non-licensed staff
How Common Are Nursing Home Medication Errors?
About 66% of all adults in the U.S. take at least one prescription drug, but this rate rises to 75% for 50- to 64-year-olds, 87% for seniors 65 to 79, and 91% for elderly people aged 80 and older according to Georgetown University’s Institute for Health Care Research and Policy. Nursing home residents are more likely to rely on prescription medications and more likely to take two or more medications every day.
How many medication errors occur each year? About 1.5 million people are harmed by medication errors and an estimated 7,000 to 9,000 Americans die as a result of a medication error every year.
The statistics on medication errors in nursing homes and long-term care facilities are frightening:
- Long-term care patients likely experience more medication errors on average than acute care hospital patients.
- 800,000 preventable medication-related injuries are estimated to occur every year in long-term care facilities.
- The overall rate of adverse medication events is 10 per 100 resident-months in long-term care facilities. About 40% of these adverse events are thought to be preventable.
The Office of the Inspector General released a 2014 report finding 1 in 3 skilled nursing facility Medicare beneficiaries were harmed by a temporary harm or adverse event within their first 35 days’ stay. About 60% of these events were preventable.
37% of these adverse events were related to medication. One of the most common issues was excessive bleeding caused by anticoagulant use which resulted in hospitalization or even death.
A 2017 study followed 25 nursing homes in North Carolina to evaluate a web-based medication error reporting system. Over one year, 23 of the 25 facilities entered 631 medication error reports for 2,731 “discrete error instances” as many mistakes happened repeatedly before they were detected. Of the 631 reported errors, 51 were reported to have a serious impact on the patient requiring intervention, monitoring, or worse. One of the serious mistakes required transportation to the emergency room and two required intervention necessary to sustain life.
The most common types of medication errors were:
- Dose omission (32%)
- Overdose (14%)
- Underdose (7%)
- Wrong patient (6%)
- Wrong medication or product (6%)
- Wrong strength (6%)
The most commonly reported causes of these errors included:
- Basic human error (48%)
- Transcription error (18%)
- Poor communication (4%)
47% of errors happened during medication administration, 38% occurred during documentation, and the rest were related to dispensing (11%), monitoring (3%), or prescribing (2%).
Licensed practical nurses (LPNs) were responsible for the medication errors in 59% of the cases followed by registered nurses (22%), support staff (11%), pharmacists (6%), physicians (1%), and medication aides (1%).
Just seven medications were involved in 28% of the prescription errors: lorazepam, oxycodone, warfarin, furosemide, hydrocodone, insulin, and fentanyl.
Antipsychotics are often prescribed to nursing home residents without a valid diagnosis and despite serious risks. A 2016 study found 16% of nursing home residents were on antipsychotic medication. 68% of residents with dementia in 57 nursing homes were taking antipsychotics and, in many cases, families and patients were not warned of the dangers or the medication was administered without consent.
Who Is Liable for Nursing Home Medication Errors?
Prescription errors can never be completely avoided, but the majority of these mistakes are preventable. Medication errors can be considered nursing home abuse or medical malpractice when they are the result of negligence by the facility or medical providers.
Multiple parties may be held liable for medication errors in nursing:
- Prescribing doctor. The doctor has a duty to review each patient’s medical history and current treatment regimen, consider drug interactions and risks, and prescribe medication that is appropriate and within the standard of care.
- Nurses and other health care providers. Negligence in medication administration and management can leave nurses and other care providers at fault.
- Pharmacists. The pharmacist who filled the prescription can be liable for errors such as providing the wrong medication or dosage.
- The nursing home. The facility can be held liable for many types of medication errors that resulted from their negligence. This can include negligent hiring or training practices, negligent supervision, inadequate systems in place, and understaffing.
A medication error lawsuit can help you recover compensation for the harm your loved one suffered and make sure they get the proper medical care they need. An experienced California nursing home abuse lawyer can help you investigate your loved one’s case, gather evidence, and hold the responsible parties accountable.
Contact a Nursing Home Medication Error Attorney for a Free Consultation
If your loved one has suffered harm from a medication error, the first step is informing your loved one’s primary care doctor or calling 911 if it’s a medical emergency. Your long term care ombudsmen can also help you as an advocate to ensure your concerns are addressed and your loved one’s health is guarded. The next step is contacting a California medication error attorney to help you explore your legal options and make sure your loved one gets the care they deserve.
Berman & Riedel, LLP is a tireless advocate for nursing home residents and their families with case results that speak for themselves. Our law firm is located in San Diego, but we accept nursing home medication error cases throughout California. Contact our law office today for a free case review with a San Diego nursing home abuse lawyer.
