Patient Given Wrong Medication
Patient Given Wrong Medication

Medication given to wrong patient or resident in a nursing home is one of many types of medication errors which occur in nursing home and other elder care facilities.  Unnecessary medication is another form of medication error which also is a frequent violation of 42 CFR 483. Nursing Home Regulations.  A great resource for determining the risks associated with a medication see the FDA Medication Guide. 

42 CFR 483. Nursing Home Regulations —(1) General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:

(i) In excessive dose (including duplicate drug therapy); or

(ii) For excessive duration; or

(iii) Without adequate monitoring; or

(iv) Without adequate indications for its use; or

(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(vi) Any combinations of the reasons above.

(m) Medication Errors. The facility must ensure that—

(1) It is free of medication error rates of five percent or greater; and

(2) Residents are free of any significant medication errors.

According to the American Geriatric Society article titled: American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. PIMs now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults. This was accomplished through the support of The American Geriatrics Society (AGS).

The American Geriatrics Society Updated Beers Criteria (AGS, 2012). The AGS Updated Beers Criteria include three main categories: (1) potentially inappropriate medications and classes to avoid in older adults; (2) potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate; and (3) medications to be used with caution in older adults.   The target population was adults over 65 in all ambulatory and institutional care settings.

Wrong Medication

The American Geriatric Society also produce valuable articles titled:

Using Medications Safely – For Elders

Avoiding Overmedication and Harmful Drug Reactions

Ten Medications Older Adults Should Avoid or Use with Caution

Medication errors, including medication given to wrong patient and medication overdose can lead to or be a contributing factor in several other forms of elder abuse and neglect including, falls, pressure sores, infections, wandering, choking and other types of injury and in some cases wrongful death.

Each resident in a nursing home must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 42 CFR 483. Nursing Home Regulations.

Medication Given to Wrong Patient
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