Types, prevalence, and potential clinical significance of medication administration errors in assisted living

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

Cross-sectional observational study.

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

Participants included 29 unlicensed assistive personnel and 510 AL residents.

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

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.

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.