Medication error

The first medication round in a new place usually takes me longer as I literally read the MAR sheets. During the morning medication round in a new placement I came across the following situation: reading through the MAR sheet I noted that one of the residents was still having warfarin following an old dosage. The blood test for INR was overdue by 2 weeks. After the medication round, I was trying to find out if the blood was sent on that day and the results may just not come back. I was not able to find any records about it.

I phoned the Anticoagulant Clinic to find out if they received any blood sample recently, and obviously, they didn’t receive anything. Their advice was to give the same dose of warfarin today and send a blood sample immediately. I took the lady’s blood and sent it off the same day. I recorded everything I have done in the daily reports, and then I photocopied the daily notes and attached to the medication error report and handed this to the home manager. When you encounter medication errors you have to record step by step what have you done to rectify the situation.


Type of Medication Error:

  • Prescribing errors
  • Omission errors
  • Wrong time error
  • Unauthorized drug error
  • Improper drug error
  • Wrong dose form errors
  • Wrong dose preparation errors
  • Wrong administration technique errors
  • Deteriorated drug errors
  • Monitoring errors
  • Compliance errors

Omission Errors – this is the failure to administer a prescribed medication. Omitted dose is not an error when: the patient cannot take anything by mouth, the home is awaiting drug level results or when the patient refuses the medication (in this case you have to document it on the back of the MAR Sheet).

Wrong time errors this can occur when:

  • The home has standardized administration times
  • Occasional unavoidable: patient is away from the home or the medication is not available at the time it is due

Improper dose errors – happens when a dose that is greater or less than prescribed dose. This can occur when the additional dose is administered through delay in documenting dose or absence of documentation.

Causes for medication errors:

  • Too many telephone calls
  • Overload/ weekends
  • Too many Patients
  • Lack of concentration
  • No one available to double check
  • Staff shortage
  • Similar drug names
  • No time to counsel
  • Illegible prescription
  • Misinterpreted prescription


“Drug use prevention is the best treatment and it cost less in lives and dollars” Frank Kelly