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Multicenter Study
. 2008 Jul;56(7):1199-205.
doi: 10.1111/j.1532-5415.2008.01754.x. Epub 2008 May 14.

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

Heather M Young  1 , Shelly L Gray, Wayne C McCormick, Suzanne K Sikma, Susan Reinhard, Linda Johnson Trippett, Carol Christlieb, Tiffany Allen
Affiliations
Multicenter Study

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

Heather M Young et al. J Am Geriatr Soc. 2008 Jul.

Abstract

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

Design: Cross-sectional observational study.

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

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

Measurements: 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.

Conclusion: 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.

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Figures

Figure 1
Figure 1
Medication error rates across facilities. NJ = New Jersey; WA = Washington; OR = Oregon. A,B,C,D = designation of individual facilities.
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References

    1. Gelhaus L. More reasons to stay. Increasing services such as medication management and extra assistance with ADLs leads assisted living providers into uncharted territory. Provider. 2001;27:18–28. - PubMed
    1. DHHS. High service or high privacy assisted living facilities, their residents and staff: results from a national survey [on-line] [Accessed August 25, 2003]. Available at http://aspe.hhs.gov/daltcp/reports/hshpes.htm.
    1. DHHS. Residents leaving assisted living: descriptive and analytic results from a national survey [on-line] [Accessed August 26, 2003]. Available at http://aspe.hhs.gov/daltcp/reports/alresid.htm.
    1. AARP. Assisted Living in the United States [on-line] [Accessed August 25, 2003]. Available at http://research.aarp.org/il/fs62r_assisted.html.
    1. Mollica R. State Assisted Living Policy: 2000. Portland: National Academy for State Health Policy; 2000.

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