How to Minimize Medication Errors in Nursing Homes
Medication errors are among the most common preventable mistakes in long-term care facilities, often leading to serious health complications or worse. Addressing this pressing issue requires a deep dive into the systems and safeguards—or lack thereof—that are supposed to protect residents. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Dr. Arnold Mackles, MD, MBA, to discuss strategies to reduce medication errors in nursing homes, highlighting the role of technology, training, and oversight in improving resident safety.
Schenk:
Reducing medication errors in nursing homes. Stick around
Hey out there. Welcome back to the nursing home abuse podcast. My name is Rob. I will be your host for this particular episode. This week we are talking about the process by which. You, the pharmacist, the physician prescribes a medication all the way down to the resident getting that medication and where that process can go wrong, but we’re not doing that alone.
All right. Now we get into the meat and potatoes of the episode. As I mentioned, we’re talking about how to reduce the likelihood of medication errors in nursing homes. But we’re not doing that alone. We have the fantastic Dr.
Mackles with us. Dr. Mackles is a seasoned neonatal practitioner, served Florida hospitals for over 22 years after completing his pediatric residency at Lenox hall hospital and NYC, and then, and a neonatal. Neonatology, Neonatology Fellowship at Cornell University Medical Center. He holds an MBA from Nova Southeastern University and a healthcare risk manager license from the University of South Florida.
Dr. Michaels has held board positions, instructed at various universities and authored online courses on patient safety. Now he focuses full time on risk management and patient safety, holding an active medical license in both Florida and New York. and New York, and he provides for the attorneys out there listening he provides expert testimony to both the plaintiff side and the defense side with respect to resident safety in nursing homes.
And we are so happy to have him on board for today’s show, Dr. Machels, welcome to the program.
Mackles:
Thank you for inviting me.
What are the most common medication errors in nursing homes?
Schenk:
So I think that obviously almost 100 percent of the population of nursing homes receive some type of medication or some type of treatment. So I guess that from a statistical standpoint, there’s going to be errors in either the administration of the prescriptions or the actual prescriptions themselves.
But in your experience, what are some of the more common common medication errors that you see in nursing homes?
Mackles:
To start there are the process delivery process for medications comprises prescribing. Okay. That’s the 1st 1 when is that’s when the doctor makes the, writes the order that’s followed by.
Dispensing, the pharmacy in the nursing home has to put the medication together, send it down to the floors where the nurses are. Then the administration, it’s when the nurses or the aides or the techs, the pharmacy techs or the medication techs give the medication. And then finally it has to be monitored.
So these are the steps that go on. And probably most of the medication mistakes occur with therapy. with dosing. Sometimes they’ll the most frequent, they’ll miss a dose or they’ll give a higher dose than necessary or a lower dose. And all this is very very complicated. When you think that, oh, the nurse shows up with a pill for you to take, it’s not quite that simple.
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Everything has to follow standards. The I know in the state of Georgia and many states around the country, Country, the pharmacies in nursing homes are really, they have to follow certain legal standards and they have to make sure that the medications are properly stored and properly dispensed and then once they’re dispensed properly they have to have trained personnel.
who give the medication. And this has to follow, it has to be overseen by a, an RN, a registered nurse. It may be given by a licensed practical nurse. And in many states, I know in Georgia they allow a certain medication technicians to give it under the supervision. But again, there has to be, it has to, start at the top.
There has to be a pharmacist overseeing the whole, process. process who has to check the doctor’s medication. Doctors make mistakes. I’m a physician, we make mistakes. We’re not, we’re human. So everything has to be checked and there has to be a, an entire process of following the medication.
All the way through from the time the doctor orders it until the patient gets it. And then the patient’s monitored and very often, if the dose is incorrect, or the medication is incorrect, patients can have, severe adverse reactions. And it’s very common that, we see mixed up medications, maybe the patient got or the resident got the roommate’s medication instead.
So the nurse or the aid giving the medication has a big responsibility and all nurses. are trained, and I’m sure the techs are trained as well, in the five rights of medication medication administration. And basically, every time a medication is given, the person who’s giving it has to go through the five rights of medication administration.
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What are the five rules of medication administration?
Is it the right drug? Is it the right dose? Is it the right route? Is it the right time? And is it the right patient? And I’m a believer that if every. Every aide or nurse who gave a medication listed those things in her mind or his mind before they give the medication, we wouldn’t have mistakes. But very often in, especially in nursing home today, especially in the years post COVID years, where often short staff, it’s hard to get good qualified people.
And they are often in a rush and overworked and, many of these events occur because of number one fatigue. From, doing so much work in a certain amount of time without the additional help of additional staff, then you have inexperienced people. It’s the responsibility of the nursing home to make sure that they have qualified, trained people from the pharmacist all the way down to the, to the aides and the staff in in the patient’s room, or, walk in the halls in the nursing home.
So they have to be trained and they have to be updated frequently. Anyone giving a medication must know the side effects of the medication how they have to monitor the medication, and especially in the elderly a lot of these medications can make them at risk for being even being drowsy or being depressed or having trouble walking or ambulating.
And so that. kicks in all the fall precautions that are often overlooked. Sure. Like a patient may be when it’s admitted, when the patient is admitted, may be fine and not have any, significant fall precautions. Yet if they’re given a medication that has a side effect of being drowsy or maybe getting a little dizzy that changes the whole process.
So patients residents have to be frequently monitored for fall precautions. And if they’re given a medication everyone has to be aware from the pharmacist down that more monitoring and perhaps more fall precautions need to be given.
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How do we prevent medication administration errors at the nursing level?
Schenk:
So you mentioned a minute ago about how one of the more common problems with the medication and the, and within the five rules is the dosage and getting the dosage correct or incorrect.
And that seems to be on the the pharmacist, the physician side. And then we have, a certain amount of common problems with respect to how the medications are managed or given through through the med tech, the RN or the LPN. What are, and I, you mentioned that sometimes when the nursing homes are over or understaffed, the people are overworked, errors in the administration of the medication can occur for those reasons.
What are some of the ways that nursing homes can better monitor or better manage the medication administration other than being fully staffed, obviously and not overworking their people? But what are some of the common ways in which we can make sure that resident A doesn’t get resident B’s prescriptions and vice versa.
Mackles:
Yeah, that’s a great question. It really starts in the pharmacy. A lot of times we see mistakes in drugs because there were thousands and thousands of drugs on the market and a lot of them sound the same. They’re called sound alike drugs or look alike drugs because the packaging is the same.
So It really starts in the pharmacy. The pharmacist has to take all the drugs that look alike or sound alike and separate them. And when an order comes in, they have to be really sure which area they’re going to. And so many mistakes are made because they put these sound alike and look alike drugs together, and the pharmacist just reaches for one and sends it down.
So these are things that The pharmacist has to check and then the nurse or the aid has a responsibility of checking the actual drug and, reading reading the label and knowing what the side effects are of the drug. So it starts there. And of course, I’m a big believer in most medical errors and mistakes are due to system errors.
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And so the system here is really at fault. When there’s a lookalike or soundalike drug, because it goes all the way back to the manufacturer who knew that the name they gave the drug sounds like seven other drugs. And the packaging looks like 10 other drugs, except for the real small print. And unfortunately the bedside nurse or track has a responsibility of, reading that small print and making sure that that dose is correct.
The second thing would be education. All of the people who give the medication have to be. educated, qualified and certified to give medication, not only in knowing which drug is which, but as I said before, knowing the side effects and delirious effects, deleterious effects of the drug. So they have to monitor the patient for that.
And so all of this should happen really before the drug is even given to the patient.
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How does staff education help prevent medication errors?
Schenk:
Okay. When in a typical situation, you, maybe you have a med tech, maybe you have an RN or LPN that maybe is new, or maybe the drug is new. Typically, in your experience where is the responsibility in terms of education come in?
So is it the pharmacist job typically to go, Hey, here’s a new drug or here’s a drug that maybe you haven’t seen before here. And so here are side effects that you should look for because resident a is already a fall risk, et cetera. Like typically where does the responsibility or probably not be a right word.
Typically, where does the education come in? In that process.
Mackles:
It really should come from the pharmacist. If the pharmacist has a new drug they’re using, they should really send down to the nurse information on it, as well as the organization, the nursing home. If they’re going to start stocking drugs that have all these complications, they really need to.
update and train the techs in the use of them. And I’m sure most of these techs who were certified and nurses who were certified have to go through certain training. However, it’s really the organization’s responsibility to have ongoing training about all these different drugs. And Whenever there’s a a misstep or something goes wrong, the organization has responsibility to do a full investigation, figure it out, and then have training sessions about how it can not occur again when these central events or these terrible events occur from These episodes.
And so I’m a big believer in communication. As a matter of fact, the Harvard Medical Industries did a study of I believe they looked at over 23, 000 malpractice cases, and they found that over 7000 of them were caused by communication breakdowns, not the nurses or the doctors training or ability or knowledge, but communication.
So all this information has to be communicated. And in that same study, I believe over 1400 people died from communication breakdowns in a five year period. So about 30 percent of these malpractice cases were due to communication breakdowns. So it’s so important for families of patient families of the residents to be on top of everything.
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How can families ensure correct medications are given in nursing homes?
Unfortunately, this is just the reality that we live in, mistakes are going to be made, especially when they’re on short staff. And so I think it’s the families need to get involved with the medication and the nurses. should be talking to the patient. Every time a new medication is given to a patient, the family has to know about it.
They have to know when it’s given, what the side effects are, how it’s going to affect their particular, their particular loved one or friend. And they unfortunately need to stay on top of it. Many years ago, when I started giving lectures in patient safety, there was an article in And the Reader’s Digest, this is going back to 2007.
And the headline on the front page was Night Shift Nightmare. And it talked about all of the nightmares that occur in healthcare facilities at night when they’re short staffed. And so much of it is due to not only they don’t have the staff, but they can’t communicate. The patients can’t communicate with the staff because they’re not around.
They may be buzzing, buzzing and no one shows up. And then they if they have to say, go to the restroom and they’re buzzing and there’s no staff there. So the resident tries to get up themselves when they should be on full precautions. Goes to the bathroom, gets dizzy, falls, cracks the skull, and you have a subdural hematoma.
And so much of this is due to staffing and communication. These organizations have to be responsive to their patients.
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Schenk:
It’s interesting that you mentioned this a few minutes ago systems, and then communication breakdowns being some of the causes of these medical malpractice claims in these injuries.
And I had read a book. I think maybe last year called the checklist manifesto, and that’s the main crux of the book is that whenever you have a quasi sophisticated objective that you’re trying to achieve, whether it’s piloting a plane or conducting a surgery, typically you’re, you might have the knowledge of step A, step B, step C, et cetera.
But just through human error you might skip a step. So that’s why pilots and surgeons might have these simple checklists that they have to click off to reduce the likelihood of. of there being some type of catastrophic or at least an injury. And I think that’s something that perhaps with this communication problem in nursing homes maybe there should be a checklist and maybe not even checklist, but like an acronym stop or whatever it is.
And it’s, Oh, that’s the communicate with the pharmacist, communicate with the director of nursing, communicate with family or whatever it is that makes it easy for them.
Mackles:
And checklists have been proven to work. A study was done by the World Health Organization in seven healthcare facilities around, around the globe.
And what they used was, it was for surgery, but it really has application in every area of healthcare. They had a 19 point checklist for before surgery, during surgery, and after surgery. And they implemented this in eight hospitals around the globe. And Unbelievably, just by instituting this checklist, they did a before and after study and just using the checklist, they were able to decrease significant errors in death by 10%.
Yeah. It was really quite amazing. I think the the number was 10%, but it definitely was a significant number just by having the checklist because we can’t possibly remember everything. Of all the residents and patients we take care of, but a checklist, or even a computer, if you’re working on a computer as a checklist, that will remember things that we just don’t remember.
Exactly. The other thing is. It is there are handoff techniques of information. Nurses are all trained in handoff techniques where when they hand off the information from one patient from one resident to another from one shift to another shift, there has to be a standardized hand handoff because you want standardized information on the patient to be handed off so the information isn’t lost in the watch.
And the Joint Commission has, several different programs that should really be followed by all health care organizations, nursing homes as well.
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Why does knowing your loved one’s baseline help reduce medication errors?
Schenk:
So we have a loved one in a nursing home. We want to make sure that we do what we can, what we reasonably can do to reduce the risk of medication errors.
What are some of the things that we can do as family members?
Mackles:
The first thing is family number members is to talk with the nurses, talk with the staff, talk with the people administration and find out what the plan is. What is the health care plan for the patient? And most health of these health care plans have medications involved in them.
So they need to know what the medications are. when they’re given and you know what the side effects are. And so it’s so important for, no one cares more about the resident than their family members. Although nurses and aides do a great job, they’re not the family and they have so many residents to take care of.
So the family needs to be in touch with it, in touch with it. And I think whenever they’re in on a frequent basis, They should, ask the nurse, what are the medications? When did you get it? You can even ask to see the checklist. Nurses have a checklist. In all these nursing homes, there’s these long, complicated charts where every time they give a medication, they’re supposed to, check it off and put their initials and the time and, residents and family, they have a right and responsibility to be able to, look at what was done to keep on top of things.
Access a wide range of health-related research and updates at the National Institutes of Health.
Schenk:
I think also perhaps even a step zero of something that you do even before, before you ask the DON or the other nursing on these questions is understand what your loved one’s baseline is first, because what difference does it make if you know what the side effects are? If you don’t know whether or not what your ba, what your loved one’s, baseline cognition is, their moods, these type of things.
So have a good understanding of that. And then when you do that. You can know if this is a side effect or if this is just how my loved one currently behaves anyway.
Mackles:
Great point. On admission to these centers, they’re supposed to do full evaluation of the skin and of their mentation.
And so it should be all in the admission information, what the baseline is. And Okay. As many things that occur in during the stay are not even covered by medic Medicare because, for example, if a patient develops a stage three or four pressure ulcer, Medicare is not going to pay for it.
So. These organizations have to do really good baseline checks and everything. Now another site I think is really very helpful is the government has a site on medicare. gov where they have a comparison of nursing home and they rate nursing homes. And for example, if you’re in Atlanta someone family can go to medicare.gov, go to nursing homes.
Stay informed about the latest drug safety alerts and approvals by visiting the U.S. Food and Drug Administration.
Type in your zip code and they’ll come up with a whole list of nursing homes and they rate them. And then under these nursing homes, you could look at certain of the quality measures that they measure. And, one of the, some of the measures include what percentage of patients changed their mentation during the stay in the nursing home, what percentage of them had.
Issues with medications. Was the issue looked into? Was it evaluated and followed up? All these things they can be compared to. So if you, your loved one is in a nursing home, you can look it up. And, if they’re rated pretty low, I think then you really need to be even more on the ball with not only, as you mentioned, the initial baseline, the zero line, but, what’s happening.
And I think that’s just a great Great way to, help you pick a place as well as following your family member that’s there.
For official healthcare policy and regulatory information, refer to the Centers for Medicare & Medicaid Services.
How has technology affected nursing home medication errors?
Schenk:
And we’ve had a couple of episodes about nursing home compare. And I’ll have those in the show notes for people to go where we just we peruse around and show you how to do it.
At least I might have to do an updated because they changed the interface last year. So I might need to do an updated episode anyway. So one last question, Dr. Michaels and that is, What does the role of technology play? In terms of reducing medication errors, like what, what has changed in your experience, maybe in the last 10 years on medication in preventing medication error?
Mackles:
In the general field the technology has really helped because they’ve gotten they’ve really gotten much more sophisticated. With the preparation of meds and sending them down to the nursing floors they have electronic carts. Now this very various different systems and companies that put out these medication carts where the medication.
It’s all computerized and the pharmacy will send the the drawers for the card or the cart down to the nursing floor where the nurse will go around and in order to open a medication for a patient, they’ll have to either put in a code or sometime it’s a thumbprint to make sure that they’re the right person opening the card and It will, they’ll need to document what the medication was to which patient in, in sophisticated situations nurses are able to also scan the medication barcode, scan the patient’s barcode, whether it’s a wrist a wristband or another means of identifying the patient and scan the medication as well as the nurse’s badge.
That way, in the electronic system, you know exactly what medication was given to what patient at what time. And it’s, if it was the wrong medication, it’s easy to go back and do an audit and see what went wrong. Or unfortunately, If you have employees who try to divert the medication or, put some medications in their pocket or shortage, and they give the someone’s medication to some other patient or other resident, all that now can be identified just by doing an audit.
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Schenk:
I don’t know. Maybe pretty soon it’ll be robots giving out the medication anyway.
Mackles:
So as a matter of fact there are many hospital pharmacies that when the order comes in electronically, it goes to the computer and is a whole big room with this rotating machine that has packets of different medications and different, um, and different doses surrounding it, the robot will get the order, will pick up the packet of medication, swing it around, put it in a packet that goes right to the nurse’s floor.
So there are definitely robotic medication systems. And again, if they’re programmed incorrectly, wrong met wrong information in, we’ll give you wrong information out. That’s right. Garbage in garbage out. It always comes down to human. It always comes down to the human. Exactly.
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Schenk:
Exactly. Dr. Michaels, we really appreciate you coming on the show and sharing your knowledge with us today. Thanks so much.
Guest Info:
- Arnold Mackles, MD, MBA on LinkedIn
- drmackles.com