Medication Errors in Nursing Homes: What Families Need to Know

Your mother seems drowsy and confused after her evening medications. Or your father developed a rash that no one can explain. Or a nurse mentions, almost in passing, that a dose was missed yesterday. Medication errors in nursing homes are not rare events. They affect 16 to 27 percent of all residents. Of the fatal, life-threatening, and serious adverse drug events, 72 percent are preventable. When your loved one takes five, ten, or more medications each day, the margin for error is razor thin – and the nursing home is responsible for getting it right.

If your loved one was harmed by a medication error in a nursing home – the wrong drug, wrong dose, or a missed medication – the facility may have violated federal pharmacy service standards. A nursing home neglect attorney can evaluate your case at no cost.

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What Medication Errors Look Like in a Nursing Home

A medication error is any mistake in ordering, filling, or giving a drug to a resident. It can happen at any point in the chain: when the doctor writes the order, when the pharmacy fills it, when the nurse gives it, or when the facility checks its effects.

The most common types include omitted doses, where staff simply forget to give a medication. A study in BMC Nursing found omitted doses in 64.8 percent of observed medication rounds. Wrong timing is the next most common, occurring 50.8 percent of the time. The same study found medication sharing between residents in 83 percent of facilities observed.

Other errors include giving the wrong dose, the wrong drug, or giving it to the wrong resident. A drug may also be given by the wrong route — such as crushing a pill that should be swallowed whole. Failing to check a drug’s effects through lab work or vital signs is another common failure.

Errors also happen during care transitions. When a resident moves between the hospital and the nursing home, drug lists often do not transfer correctly. The National Academies found that 40 percent of medication errors occur during these transitions.

The scale is large. AHRQ estimates about 10 harmful drug events per 100 resident-months, with about 40 percent preventable. A Cochrane review found that 90 percent of residents were exposed to at least one medication error over 3 months.

Warning Signs of a Medication Error

You do not need medical training to notice that something is wrong. Watch for these signs during visits:

• New drowsiness, confusion, or unresponsiveness that started after a medication change
• Unexplained rashes, swelling, or hives
• Nausea, vomiting, or diarrhea that was not present before
• Unusual bruising or bleeding, which can signal problems with blood thinners
• A sudden change in blood pressure, heart rate, or breathing
• Falls that coincide with new medications or dosage changes
• Your loved one reports not receiving a regular medication
• You notice different pills than usual in the medication cup
• Staff seem rushed, distracted, or unfamiliar with your loved one’s medication routine
• The facility cannot produce a current, accurate medication list when you ask
• Your loved one’s condition worsens without a clear medical explanation

Pay close attention after hospital stays, when drug lists change. That is when errors are most likely to happen.

When the Nursing Home Is Responsible

Federal law requires nursing homes to manage drugs safely. This means keeping an accurate drug record for each resident and following the doctor’s orders exactly. A licensed pharmacist must review each resident’s drug regimen at least monthly. The facility must watch for side effects and drug conflicts, train staff on safe practices, and look into errors when they occur.

The nursing home cannot blame the pharmacy, the doctor, or the hospital. The facility is responsible for every step that happens within its walls. That means checking orders, verifying allergies, giving the right drug at the right time, and watching the resident afterward.

Staffing plays a direct role in medication safety. The BMC Nursing study found that understaffing (36.6 percent), interruptions during medication rounds (75.6 percent), and stress (42.3 percent) were the main factors contributing to errors. When a nurse is responsible for 20 or 30 residents and is constantly interrupted, mistakes happen.

Some drugs carry higher risk than others. Sedatives, antipsychotics, antidepressants, and blood thinners like warfarin are linked to the most serious harmful events. AHRQ found that less than 50 percent of warfarin therapy in nursing homes stays within safe levels. The 2023 AGS Beers Criteria lists drugs that are risky for older adults and need close monitoring in nursing home settings.

Ask the facility for the current medication list, the most recent pharmacist drug review, and the medication records for the past week.

What Happens When Medication Errors Go Unchecked

A single medication error can start a chain of harm that grows worse over time.

A missed blood thinner dose can lead to a blood clot. A wrong antibiotic can let an infection progress to sepsis. An unnecessary sedative can cause a fall, a broken hip, immobility, and then a bedsore. Each error creates vulnerabilities that compound.

The American Journal of Medicine study found 1.89 harmful drug events per 100 resident-months in nursing homes. That may sound small until you consider that nursing homes serve 1.2 million residents. The numbers add up to thousands of preventable injuries every month.

When monitoring fails, the harm multiplies. A resident on warfarin whose blood is not checked regularly can bleed internally for days before anyone notices. A resident developing an allergic reaction may be given the same medication again if the error is not documented.

AHRQ’s 2014 Office of Inspector General study found that 22 percent of Medicare patients in skilled nursing facilities experienced a harmful event. About half were preventable. Drug-related events were the most common type.

In severe cases, medication errors lead to wrongful death. A fatal error is not an accident when it came from skipped safety steps, short staffing, or failure to watch a high-risk drug.