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


METHODS
Cross-sectional observational study.


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


METHODS
Participants included 29 unlicensed assistive personnel and 510 AL residents.


METHODS
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.


CONCLUSIONS
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.
Young
Heather M
HM
School of Nursing, Oregon Health and Science University Ashland, Oregon 97520, USA. younghe@ohsu.edu
Gray
Shelly L
SL
McCormick
Wayne C
WC
Sikma
Suzanne K
SK
Reinhard
Susan
S
Johnson Trippett
Linda
L
Christlieb
Carol
C
Allen
Tiffany
T
D000369:Aged, 80 and over; D000488:Allied Health Personnel / Q000145:classification* / Q000193:education; D040561:Assisted Living Facilities / Q000592:standards / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D004522:Educational Status; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000145:classification / Q000706:statistics & numerical data*; D015995:Prevalence; D014481:United States / Q000453:epidemiology