‘Significant Medication Errors’ Discovered In Nursing Home Following Investigation Related To Patient Injury & Death

Picture-332Following a medication-error related death and other medication-related problems that resulted in patient injuries, Minnesota Department of Heath investigators concluded that Fair Oaks Lodge in Wadena, MN was guilty of neglect and other federally mandated nursing home standards.

The ‘major medication errors’ occurred within 16 days of one another.  According to the State’s investigative report:

  • A medication aide mistakenly gave an Alzheimer’s patient drugs for her central nervous system, the heart and anti-psychotic medication all of which resulted in an immediate drop of her blood pressure.  Despite being rushed to the emergency room, the elderly woman died three days later.
  • A patient was hospitalized after receiving two does of Tylenol within two hours and an improper medication related to hypertension
  • A third nursing home patient was hospitalized after a nurse administered medications a medication aide had intended for another patient.

Despite the serious medication-related problems at Fair Oaks, state investigators still found a medication error rate of 18% 2 1/2 months later.  Read more about these medication errors in a nursing home here.

Medication Errors

In the nursing home setting, some of the more common medication errors include:

Administering The Incorrect Prescription

Medication errors can result when there is a mis-communication or misunderstanding of drug orders. These errors may be due to: poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations. Doctors must take reasonable care in correctly and accurately writing prescriptions and staff must similarly confirm medication types and dosages when in doubt.

Medication errors can also occur when doctors take an incomplete medical history from a patient. For example, the doctor might not know about the patient’s allergies, any other medications the patient is taking, previous diagnoses, and lab results. Nursing homes should help treating physicians by ensuring that they provide the physician with accurate medical charts.

Failure to Consider Adverse Side Effects of Drugs

Many prescription (and over-the-counter) medications have serious side effects that should be considered before taking them. Some serious and common side effects include: allergic reactions, heart problems, liver and kidney failure, weight gain/loss, and psychological effects. The doctor prescribing your medication should consider the pros and cons of prescribing the medication as opposed to leaving the condition untreated or prescribing a different medication. Similarly, the staff in a nursing home, should monitor patients to help detect adverse reactions as quickly as feasible.

Incorrect Medication Dosage

Prescription medications have more serious dangers associated with them than over the counter (OTC) drugs. Therefore, it is important that nursing home staff issue the correct drug (the one the doctor prescribed) at the correct dose. At many nursing homes and medical facilities, medications are administered via a ‘medication cart’ where many similar-looking pills are stored. Consequently, staff in nursing homes must check and re-check before administering medication to assure the patient receives the proper dosage.

Medical complications may arise when patients are administered too much or too little of a drug. Many prescription medications require must be taken at a specific time, staff must be aware of these administration parameters and dispense the medication accordingly.

Adverse Drug Interactions

Many older adults, take multiple prescription medications, which are commonly prescribed my multiple doctors. However, problems can occur because the doctors prescribing these medications might not know about the other drugs you are taking. This can lead to serious complications stemming from drug interactions. Drug-drug interactions are not the only type of potentially dangerous drug interactions; there can also be drug interactions with foods, beverages, and dietary supplements.

There are three main types of drug interactions:

  • Drugs with food and beverages
  • Drugs with dietary supplements
  • Drugs with other drugs

Drug interactions can reduce the effectiveness of drugs, cause unexpected side effects, or increase the action of a particular drug. Drug interactions with food and beverages might result in delayed, decreased, or enhanced absorption of a medication. Dietary supplements can also cause a variety of drug interactions, and with fifty percent of American adults using dietary supplements (vitamins, minerals, amino acids, herbs or botanicals) on a regular basis, the risk of negative drug interactions is high.

Nursing Home Liability for Medication Errors

Medication error cases can frequently be some of the more complex cases due to the fact that a variety of parties may be responsible for the error(s). In some cases, liability may be imposed on the physician, nursing home and pharmacy involved in the incident. Consequently, in order to fully investigate each parties culpability, it is important to speak with a lawyer experienced in handling cases involving medication errors as soon as feasible after the event.

Learn more about the laws applicable to Minnesota nursing homes here.
Click on the links for information on nursing homes in Minneapolis , Rochester and St. Paul

Related Nursing Home Law Center LLC Blog Entries:

Medication Aides In Nursing Homes: A Push To Save Money Or Improve Patient Care?

Study Shows Errors In Timing Of Administration Of Medication In Assisted Living Facilities

Improper Drug Dosage, Wrong Medication, Interactions With Other Drugs…. May Be The Result Of Pharmaceutical Malpractice


0 responses to “‘Significant Medication Errors’ Discovered In Nursing Home Following Investigation Related To Patient Injury & Death”

  1. 1concernedMedTech says:

    I know this to be true because I’m dealing with this situation right now in Georgia! I am a Medication Technician through Omnicare and can’t believe how they allow Resident Assistants to give meds without proper training! The RN at the facility turns a blind eye on employees crushing meds without doctors orders. They miscount meds and log wrong! Then YOU are the problem when you bring it up! I ended up not being put on the schedule and now I hear through the grapevine that I’m on PRN status! How convenient for the nurse is that? She doesn’t want anyone who KNOWS the do’s and don’ts of giving meds. Just shut up and give it! Oh that includes charting that you gave it knowing you really didn’t!!! What is this world coming too?!!!

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