Medication administration in nursing homes is a task that requires time, attention, and knowledge of the required components of the task. Due to the complexity of resident needs and the volume of drugs administered, the potential for error is high. According to the State Operations Manual Appendix PP, surveyors observe for two levels of medication errors during their annual survey at any facility: the facility must be free of medication error rates of 5 percent or greater, and residents must be free of any significant medication errors. A medication error is considered to occur when the preparation or administration of the drug is not in compliance with the prescriber’s order, the manufacturer’s specifications, and/or accepted professional standards and principles. A significant medication error is one that causes the resident discomfort or jeopardizes his or her health and safety. For example, if a resident has an order for a laxative to relieve constipation, and the administration is missed for one day, it may have little or no impact on the resident, and is counted as a medication omission error. But if the medication is omitted for three or more days, and the resident experiences an obstruction or fecal impaction, the omission has caused discomfort and jeopardizes the resident’s health. It then rises to the level of a significant medication error. The relative significance is a matter of professional judgment that is made by considering three guidelines: the resident’s condition, the drug category, and frequency of the error.
Medication errors fall under a variety of categories, and include the following:
- Medication is ordered but not administered at least one time
- Medication is administered without a physician’s order
- The wrong dose is administered
- The wrong route of administration is used
- A wrong dosage form is administered
- The wrong medication is given
- The individual administering the medication fails to follow manufacturer specifications or accepted professional standards.
There are many actions or non-actions that fall under this last category of errors, including failure to shake well; crushing of medications that should not be crushed; administration without adequate fluids; medications that must be taken with food or on an empty stomach; administration via feeding tubes without proper flushes or placement checks; eye medication instillation that fails to make contact or that is not properly spaced between a next administration; sublingual medications that are swallowed; and metered dose inhalers not used properly.
To be considered safe administration, the process should include administration of the right medication at the right dosage to the right individual via the right manner and route at the right time. It should include the right documentation and the right assessment, such as taking a pulse or blood pressure if appropriate. The patient/resident who can comprehend should receive the right education about the drug, such as what to expect, and any food or beverages to avoid. The resident should receive the right observation to assess the outcome of the medication. Staff actions that deviate from standards of practice for safe administration include diverting medications, borrowing medications, and failing to maintain an adequate supply of medications for the resident.
To support accuracy in medication administration, staff assigned to conduct the “med pass” should receive education that prepares them to perform accurately and to avoid committing errors. Observation of their technique and accuracy should be conducted periodically to ensure they are competent in administering the wide range of drugs and routes present in your setting. Education is a key component in keeping medication administration safe. Your pharmacist is an expert resource who can assist you by providing education about medications, manufacturer specifications, and observations that should be made. He or she can participate in the competency observation process. Medication administration is a complex task with the potential to help or harm your residents. Include your pharmacist in your team’s efforts, and make medication administration as safe as possible for each resident in your care.
For more information on CMS requirements and a listing of examples of significant and non-significant medication errors, access F-Tags 332 and 333 at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.