The most common medication mistakes in long-term care

Hydromorphone was the medication most commonly involved in medication incidents in long-term care that were included in a recent ISMP Canada analysis. The analysis was done in partnership with Ontario’s Ministry of Long-Term Care as part of an initiative to improve medication safety and help address recommendations from the Gillese Inquiry. This report examined 190 incidents between June 1, 2021 and July 31, 2023. They came from the National System for Incident Reporting database and ISMPC’s database. Hydromorphone was involved in 11% of the incidents, Trazodone in 7%, Acetaminophen in 4%, Denosumab in 3% and Amoxicillin in 3%. Read: ISMP Canada: Pharmacies caught 700+ near misses in one month alone. Here’s what they taught usMost incidents caused mild or no harm, but 5% (or 10 incidents) led to moderate or severe harm or death. Errors were made while processing or entering orders (38%), administering medications (33%), dispensing (15%), prescribing (5%) and monitoring (3%). One of the themes ISMPC found was difficulties with identifying residents who may not be able to say their name and birth date and don’t wear ID wristbands. An example was given when a resident was moved to a different room during an outbreak and given the wrong medications by a nurse as a result. The medications included insulin, long-acting morphine and rivaroxaban and made the resident so sick they had to stay in the hospital for an extended period of time. Read: The five most common e-prescribing errors: ISMP CanadaAnother pressure point was the complex medication order prescribing process in LTC, which is done through handwritten or verbal orders as well as computerized systems. This included mistakes around medication dispensing, confirming medication orders, and order entry. Issues with communication around medications were another theme. That included incomplete medication reconciliation and difficulties around atypical dosing schedules. For example, one resident was supposed to receive denosumab every six months. Yet even though he had a dose less than a month before being admitted, that information wasn’t obtained by the long-term care facility. In addition, he was given three more doses monthly while at the LTC facility. The resident had severe kidney injury as a result. Finally, the report highlighted the potential for residents and families to be more informed about medications and their role in preventing errors. Read: ISMP Canada analysis highlights errors that can happen with look-alike high-alert medications

The most common medication mistakes in long-term care

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