One Patient’s Tale of Medication Errors in Long-Term Care

I often cite research regarding the frequency and severity of medication errors. The Institute of Medicine estimates the average patient in hospitals and long-term care facilities experiences at least one medication error each day! The report also states there are 1.5 million preventable adverse drug interactions each year in US hospitals and long-term care facilities. Today’s post covers one patient’s tale of medication errors during several stays at long-term care facilities.

Note: Read the companion post to learn more about how to reduce the risk of medication errors in rehab and long-term care facilities.

What Causes Medication Errors?

Errors can occur at any step in the process. Medical staff can make mistakes when prescribing, ordering, dispensing, preparing or administering drugs. Patients can get the wrong medication, the wrong dosage of the correct medication, or get the right medication at the wrong time.

How does this happen? There are a variety of factors leading to medication errors, including staff fatigue and/or shortages, hospital overcrowding, and insufficient training.

Think there’s no way this could happen to you? You’re wrong – it can easily happen to you and maybe already has, without you even noticing.

One patient’s tale of medication errors in long-term care.

Rose is in her 80s and suffers from severe osteoporosis. She breaks bones frequently and often ends up in long-term care/rehab facilities to recover.

She also has diabetes, high blood pressure and a few other medical conditions. Fortunately, she is sharp as a tack and stays on top of her medical care like a hawk. Which has probably saved her life several times. These are her stories.

A nurse thought she was a different patient.

After breaking her hip, Rose entered a rehab facility. She agreed to let the staff dispense all her medications, including her insulin injections for diabetes.

One morning, a nurse came in at 6 am holding a needle. When Rose asked what the injection was, he replied it was her medication.

She told him that she never had her insulin injection at 6 am. He insisted that she did. She insisted that she didn’t.

The nurse replied “your doctor ordered it” while he simultaneously gave her the shot. Rose didn’t have a chance to insist that he check her records – he stabbed her with the needle with no warning.

Thirty minutes later, Rose’s daughter calls to tell her that a nursing manager called to tell her they had given Rose the wrong medicine by mistake.

The manager told her daughter not to worry because Rose was “still conscious”. Her daughter immediately drove to the facility to check on her mother. Unsurprisingly, after such a big error, the director of the facility and the head nurse join the mother and daughter.

They apologized and told Rose that the medication had indeed been for another patient. Shockingly, they never told Rose what medication was given to her in error. Rose, and the facility, are quite lucky that Rose wasn’t harmed by the medication.

A nurse gave her the wrong medication.

During her stay at a different facility Rose’s alertness prevented a serious medication error. When a nurse gave Rose her medications, Rose noticed a pill that didn’t look like her regular pills.

Rose asked the nurse what the pill was, and the nurse responded that it was her blood pressure pill. Rose replied that it wasn’t. The nurse insisted it was the correct pill.

Rose told the nurse that it looked like aspirin which she is allergic to. Rose refused to take the pill and asked to see the head nurse. The nurse returns with the head nurse, who addressed Rose. Here is how the conversation went:

Head nurse: “What’s the problem?”

Rose holds out the pill in question and asks: “What’s this pill?”

Head nurse: “It’s just an aspirin dear”

Rose: “That’s the problem. It was given to me as my blood pressure pill. I am allergic to aspirin which you can see on my chart”.

The head nurse took the aspirin and brought back the correct blood pressure pill. Because Rose was insistent, she prevented a potentially dangerous reaction.

Interestingly, as her stay continued in this facility, many other patients came to Rose with issues regarding their own medication errors. The patients were so concerned about these ongoing medication errors, they considered suing the facility.

What can you do to reduce your risk of medication errors?

It’s scary to think that a medication error while you are in a long-term care facility can make you sicker than when you went in. Fortunately, there are some things you can do to reduce your risk of medication errors for yourself or a loved one – read How to Reduce the Risk of Medication Errors in Rehab Facilities.