Common Medication Errors in LTC Communities: What Pharmacists Can Do To Help Prevent Them


The most common medication errors seen in LTC facilities include dispensing errors, delay in delivery, and expired inventory.

In the long-term care (LTC) setting, pharmacists are essential in the prevention of medication errors. We need to strive to minimize or even eliminate the most common medication errors to ensure we provide the highest-quality care for our patients.

The most common medication errors seen in LTC facilities include dispensing errors, delay in delivery, and expired inventory. Dispensing errors entail incorrect dose, incorrect drug, incorrect patient, incorrect route, and incorrect time. Lookalike and soundalike drugs are among the biggest causes of medications errors seen in the pharmacy.

For instance, hydroxyzine and hydralazine is one prime example where if not careful, a completely different medication with a different indication would be dispensed. The pharmacy should use the list provided by the Institute for Safe Medication Practices to assist in minimizing these types of errors.

Incorrect compliance blister and foil packaging also account for a considerable share of dispensing errors in LTC pharmacies. Blister packaging ensures that the right dose is given at the right time efficiently. The pharmacy must inspect each bubble and double check the foil for accuracy. For example, the foil must have the correct lot number, medication name, and “use by” date.

Partial tablets are another category where dispensing errors commonly occur. As per regulations in many LTC facilities, the nursing staff must rely on the pharmacy to partial-tablet any order—if allowable—that is not readily available in the required strength. The pharmacy can prevent these types of errors by adding warning notes in the pharmacy software to double check for partial tablets and to educate pharmacy technicians and pharmacists to verify directions on each label prior to filling and dispensing.

Delays in delivery can also lead to medication errors in that the medication will not be available in a timely manner for the facility to administer. The pharmacy can improve and prevent these issues by having constant open communication with the staff and the facility.

Delays are commonly associated with high prescription volume days, staff shortages, or a failure to dispatch drivers on time. Pharmacy communication is vital in providing alternatives for the facility if the prescribed medication will not be delivered in time. The dispensing pharmacy can also transfer the medication—if allowable—to a local retail pharmacy, where it can be picked up by a local driver or a staff member to avoid any delays in delivery.

Regarding expired inventory, the pharmacy can help prevent errors by proactively performing monthly checks. In addition, while filling the medication, the staff should always double check expiration dates and lot numbers prior to releasing the medication for the pharmacist to review.

The transition from the hospital to the LTC facility can be very complicated and confusing. Patients can be new admissions or re-admissions to the facility. Most medication errors are seen when a resident is transferred to the hospital and then readmitted back to the facility with different medication based on what the hospital prescribed.

As pharmacists, we must always check the previous medication history and confirm the meds that were prescribed in the hospital are supposed to be continued upon admission at the LTC facility. Pharmacies can assist in minimizing these errors by questioning any discrepancies and reaching out to the nursing staff if there are any duplication of therapy, any addition of new medication, or changes in current medications.

To improve and minimize preventable medication errors, each pharmacy should use a medication incident and discrepancy report. Each medication error that is reported—whether internal at the pharmacy or external where the medication has been dispensed to the facility—must be documented.

The form should include all details of the type of incident (e.g., incorrect dose, incorrect drug, incorrect patient, expired medication, etc) and incident description of what transpired. The pharmacy will assess the severity of the error and document it. This would enable the pharmacy to have accountability while providing continuing education to the staff on the trends of the type of errors that have been committed.

In conclusion, medication errors will happen from time to time, but as pharmacists we can do our part and strive to become more vigilant in minimizing these errors by addressing common issues and proactively educating our staff to ensure we improve the quality of care for our patients.

About the Author

Nirav Pandya, PharmD, RPh, is a supervising pharmacist at Community Care Rx, a long-term care pharmacy serving assisted living facilities, nursing homes, OPWDD group homes, and other long-term care facilities. Community Care Rx has offices in Hempstead, NY, and Totowa, NJ.

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