in practice

in Practice

Recognizing and Preventing

Medication Administration Errors
Proper medication administration in the long-term care facility is vitally important, as many medications have specific
administration parameters that are essential to their optimal efficacy. Pharmacists servicing long-term care facilities play an
integral role in observing medication administration in the facility and educating facility staff on proper administration techniques.
By being vigilant to potential problems, pharmacists can help ensure that facility residents receive their medications appropriately.

KEY WORDS: Administration, Elderly, Error, Feeding tube, Inhaler, Long-term care, Medication, Medication administration record,
Medication pass, Med pass, Nursing facility.

Abbreviations: CMS = Centers for Medicare & Medicaid Services, eMAR = Electronic medication administration record,
IV = Intravenous, MAR = Medication administration record.

Acknowledgement: The authors wish to thank the consultant pharmacists who contributed their stories about actual
patients for this article.

Caren McHenry Martin, Gianna Bryan

A nurse administering medications during a A prescriber wrote an order for Talwin 45 mg by

medication pass (med pass) in a long-term facility
reads a new order on the medication administration
record (MAR) to give an oral Percocet 10/325 mg
tablet. The consultant pharmacist observing the nurse
watched her select a container of Percocet 5/325 from
the cart. As she began to open the packaging, the
pharmacist pointed out that she had pulled Percocet
5/325 instead of Percocet 10/325. “That’s right. I just
give two of them,” the nurse responded. “The order just
got changed and I want to use these up.” Upon review
of the other medications ordered for the resident,
the pharmacist discovered this “double dose” caused
the patient to exceed the recommended daily dose of
acetaminophen by more than 2 grams.
mouth every six hours as needed for pain. Since the
oral formulation is only available in the 50 mg dose,
the order was clarified by the pharmacy to be 50 mg
by mouth every six hours as needed for pain and was
dispensed. However, the order was not changed on the
MAR and continued to be listed on the MAR as 45 mg.
The consultant pharmacist reviewing the MAR noted
the 45 mg dose listed and began to investigate what
was being given. The nurse administering medications
informed the pharmacist that the 45 mg dose was
correct, and that she had been giving it without any
problem. She then proceeded to demonstrate how she
took the 50 mg tablet, and—using a fingernail file—filed
off what she estimated as 1/10 (5 mg) of the tablet so the
remaining tablet would equal 45 mg.

272 The Consultant Pharmacist   may 2013   Vol. 28, No. 5

S
tories like these—real stories submitted by
practicing consultant pharmacists—occur com-
monly in the long-term care setting. Consultant
pharmacists working in long-term care routinely
encounter situations like these when they observe nurses
administering medications to facility patients. While
nurses receive medication administration training in
nursing school and ongoing education in the long-term
care facility, gaps in their knowledge and education may
still exist, and consultant pharmacists play a key role in
detecting, correcting, and preventing these errors. And it’s
important that consultant pharmacists help reinforce the
well-known “rights” of medication administration: Right
Patient, Right Medication, Right Dose, Right Route, Right
Time. Pharmacists can explain to nurses that any error
in ensuring these “rights” is a medication administration
error, regardless of whether the patient is actually harmed
by the mistake.
Math Mistakes
Many medication administration errors occur as a result
of math mistakes. A nurse may calculate the wrong
number of milliliters to be administered for a medication
ordered in milligrams, for example. And, since nurses are
often unfamiliar with the variety of liquid formulations
available, they may make a fatal dosing error if they fail to
recognize that a medication—like an opioid—is dispensed
as an oral concentrated solution. That’s why it is important
for pharmacists to ensure that all liquid medications are
labeled in terms of both dose (mg) and quantity (mL) on
the prescription label and the MAR. For oral medications,
a best-practice procedure is to list both the total dose and
the number of tablets/capsules needed to obtain the dose
(e.g., acetaminophen 325 mg, two tabs = 650 mg). It is also
important that pharmacists who are reviewing the patient’s
medications be on alert for doses that are difficult to
measure (e.g., 8.75 mL) and dosage forms that don’t exist
(such as the Talwin dose, described above). Procedures for
clarifying orders should include safeguards such as writ-
ing a new “clarified” order and ensuring this order goes
through the process of getting transcribed to the MAR.
Nurses should be counseled that it’s never acceptable to
The Consultant Pharmacist   may 2013   Vol. 28, No. 5  273
“eyeball” or estimate a dose of a liquid medication; and
if the exact amount cannot be obtained from a standard
measuring cup or syringe, the nurse should contact the
pharmacy for clarification. For consultant pharmacists
in the long-term care facility, periodic spot checks of
the medications in the cart can be beneficial in spotting
potential sources of error. If, for example, a pharmacist
notices that some patients have orders for calcium 500
mg and some have orders for 600 mg, (both obtained
from floor stock bottles), the pharmacist can check to
ensure both products are found on the cart. And, since
the pharmacist is not always in the facility, it’s essential
that he or she establish camaraderie with the nursing
staff so that nurses feel comfortable calling the pharmacy
with questions if they are unsure how to administer a
particular medication. A good working relationship
with an easily accessible pharmacist can help ensure that
nurses clarify these questions with the expertise of a
pharmacist, rather than make incorrect assumptions that
could endanger patients.
Pharmacists can ensure that current “Do Not
Crush” lists are easily accessible to nursing staff.
Tube Trouble
A state surveyor observed a nurse during the
facility’s annual survey process. The patient had
several medications that needed to be crushed and
administered via g-tube (this is usually accomplished
by a sequence of events including flushing the tube
with water then mixing crushed medications with
additional liquid that is poured into the tube). This
nurse simply crushed the medications and poured the
dry powder into the g-tube, resulting in a blockage
midway down the tube. The nurse tried to flush the
powder through the tube by injecting saline with a
syringe, which resulted in a backflow of fluid that
sprayed all over the patient, nurse, and surveyor
(fortunately, the patient was not harmed).
 Recognizing and Preventing Medication Administration Errors
Feeding tubes can be a major source of medication
administration error. Nurses who come to the long-term
care setting from other nursing environments may be
unfamiliar with administering medications via tube.
Or, there may be experienced nurses who were taught
practices that are no longer preferred standards of prac-
tice. Perhaps most important, nurses may be unaware
of the policies specific to their facility and may follow a
protocol that is inconsistent with the facility’s policies
and procedures. The importance of a facility having
(and a nurse knowing) specific policies and procedures
for administration via feeding tube was highlighted in
a November 2012 memorandum from the Centers for
Medicare & Medicaid Services (CMS). This memo, to
state survey agency directors, clarified its rules related to
medication errors and pharmacy services:
…the facility, in consultation with the pharmacist,
must provide procedures for the accurate
administration of all medications. The procedures
must reflect current standards of practice including
but not limited to: types of medications that
may be safely administered via a feeding tube;
appropriate dosage forms; techniques to monitor
and verity that the feeding tube is in the right
location (e.g., stomach or small intestine, depending
on the tube) before administering medications;
preparing drugs for enteral administration,
administering drugs separately, diluting drugs as
appropriate, and flushing the feeding tube before,
between, and after drug administration; and that
medications with known incompatibilities must
not be given at the same time (http://www.cms.gov/
Medicare/Provider-Enrollment-and-Certification/
SurveyCertificationGenInfo/Downloads/Survey-
and-Cert-Letter-13-02.pdf).
The memo further reminds surveyors that standards
of practice include checking for tube placement before
giving medications via tube and giving each medication
individually via tube followed by a flush. Facilities may
need their consultant pharmacist to inform them of
this CMS memo to ensure their policies are current.
Knowledge of which medications can and cannot be
crushed may be lacking, and the medications may not
274 The Consultant Pharmacist   may 2013   Vol. 28, No. 5
always be labeled with “Do Not Crush” stickers from the
pharmacy. Pharmacists can ensure that current “Do Not
Crush” Lists are easily accessible to nursing staff. As an
additional safety feature, some pharmacies and facilities
put “Do Not Crush” in the medication directions on the
MAR. Dispensing pharmacists can review the existing
orders on a resident who has recently had a tube placed
and ensure the orders are appropriate to give via tube.
And, since medication administration via tube is often
a focus of the state survey, pharmacists can assist the
facilities by routinely observing tube administration
prior to the surveyor’s visit.
Route Risks
One of our patients had an order for Tussionex
Suspension 5 mL by mouth, which she had been taking
at home before admission. The pharmacy dispensed
the 5 mL doses in clearly marked oral syringes. As an
added safety feature, the oral syringes were amber
colored, as opposed to the clear syringes typically
used for injectable medications. The nurse, however,
assumed the syringes were for injection. When she
went to secure it to the intravenous (IV) line, the
patient herself told the nurse that she had been taking
it by mouth. The nurse then realized her error. This
could have turned out differently if the patient had not
been familiar with the medication she was receiving.
While making sure the medication is given by the
correct route seems intuitive, there are many exceptions
to the rule that can throw off even the most seasoned
nurse. For example, atropine eye drops often are ordered
to be given sublingually for patients with excessive sali-
vary secretions. Oral morphine doses may be dispensed
in prefilled syringes, rather than in the bottle, for safety
and accountability purposes. Some medications for ear
infections are taken orally, while others are administered
directly into the ear. It’s crucial that that pharmacist be
attuned to these potential sources of error. Are the atro-
pine drops being stored with other eye drops (that might
indicate that staff is not administering them sublingually
as ordered)? Are the oral syringes being kept with IV
supplies? Does the MAR clearly state that the ciprofloxa-
cin otic drops should be placed into the ear? Looking for
clues such as these, even if only on a “spot-check” basis,
can enable the pharmacist to prevent potential administra-
tion errors.
Technology Trip-ups
A facility recently implemented an electronic medication
administration record (eMAR) system, and nursing
staff were still learning how to enter medication orders
in the system. A patient had an order to decrease an
omeprazole 20 mg order from twice-daily to daily. The
twice-daily dosing schedule had been entered in the
computer as 0900 and 1700. The daily schedule was
entered as 0630. The nurse who received the order to
switch from twice-daily to daily entered the daily order,
but forgot to properly discontinue the twice-daily order.
This resulted in the patient having a dose of omeprazole
scheduled at 0630 (given by night shift), 0900 (given by
day shift) and 1700 (given by evening shift). Since the
computer system only showed the nurse the medication
orders that were due at each dosing time during the med
pass operation, none of the three nurses realized that
other doses were being given on the other shifts.
Fortunately, a sharp-eyed consultant pharmacist
prevented this excessive medication dosing. eMARs offer
many benefits, including ease of medication administra-
tion, real-time checks, and reminders to staff to prevent
omitting a medication. Despite these benefits, each system
also contains its own unique ways for errors to occur.
While some systems interface with pharmacy dispens-
ing systems, others require the facility to input its own
orders into the computer. Thus, there is often no mecha-
nism by which the pharmacy can verify order accuracy of
the eMAR in the facility. A simple keystroke in the wrong
field can cause the order to have the wrong administration
times appear or not to appear at all on the eMAR. If the
dispensing pharmacy is unable to view what was entered
in the facility, the consultant pharmacist (who is often only
in the facility a few days per month) may not catch the
errors until long after they occur.
Regardless of the system the facility is using, it is
imperative that the consultant pharmacist have a working
knowledge of the features of the program. The eMAR for
every resident reviewed should be accessed electronically
The Consultant Pharmacist   may 2013   Vol. 28, No. 5  275
or on paper while completing the monthly facility review
to ensure medications are being given at the right times, in
the correct dosage forms, and for the prescribed durations.
If the facility is responsible for entering the orders onsite,
developing a relationship with the staff involved in this
process is necessary for the consultant pharmacist who can
serve as a resource and help prevent errors.
Inhaler Idiosyncrasies
When the Spiriva Handihaler [that requires a capsule
containing medication be placed into the inhaler and
then inhaled] came on the market, I had an “I can’t
believe it” moment while observing a med pass. The
nurse I was watching opened the Handihaler, pulled out
a capsule, and put it in the cup of medications for the
patient to swallow. When I asked her about it, she said
the she thought the Handihaler was a case for the capsule
to be stored in so the patient could take the capsule any
time. I immediately scheduled an inservice on giving
Spiriva in that facility!
Inhalers used to be straightforward: Inhale aerosol
from the mouthpiece as the canister is depressed. Now,
however, since the Food and Drug Administration issued
a ruling in 2005 that required the transition of CFC (chlo-
rofluorocarbon) to HFA (hydrofluoroalkane) propellants,
many inhalers incorporate novel dose-delivery systems.
The person giving medications must be aware of the
mechanism of several different kinds of inhalers, each with
its own idiosyncrasies, as well as understanding the proper
timing for each inhaler. The November 2012 CMS memo
to state surveyor directors clarified the use of metered dose
inhaler timing as follows:
If more than one (1) puff is required (whether the
same medication or a different medication), current
guidelines, and/or manufacturer product information
indicate there should be a waiting time of approximately
one (1) minute between puffs except for short-acting
beta-agonists such as albuterol, where a shorter wait
time of 15-30 seconds is acceptable ((http://www.cms.
gov/Medicare/Provider-Enrollment-and-Certification/
SurveyCertificationGenInfo/Downloads/Survey-and-
Cert-Letter-13-02.pdf).
 Recognizing and Preventing Medication Administration Errors
Need Additional Resources?
The American Society of Consultant Pharmacists
(ASCP) and Med-Pass, Inc. have codeveloped several
resources to provide guidance for pharmacists, nurses,
and medication administration aides about the best
practices for administering medications. The following
are available for purchase at http://www.med-pass.
com; ASCP members receive discounted pricing.
• Passing Medications: ASCP’s In addition, Med-Pass, Inc., a publishing company,
Medication Administration Video Series
This two-part video series was created to train care
staff in the proper preparation and administration of
all types of medications. Additional areas of concern,
such as order transcription and documentation,
regulations, and resident dignity and safety are also
included. Topics are presented in separate modules
with an accompanying CD that contains PDFs of the
handouts, making inservices quick and manageable.
• Medication Pass Observation Reports
Available as a two-part or three-part carbonless
form, this tool is designed to provide comprehensive
documentation for observation of the medication pass,
including identification of error types and calculation
of error rate. These forms were recently updated to
reflect federal changes regarding “Medication Errors
Due to Failure to Follow Manufacturers Specifications
or Accepted Professional Standards,” with examples
of associated errors listed. In addition, the Medication
Administration Pocket Guide for Assisted Living and
Nursing Home Medication Technicians is available.
This easy-to-understand pocket guide provides
guidance for medication technicians (aides) that
provide medication assistance to residents in assisted
living and nursing homes.
• Medications Not to Be Crushed
This handy reference card lists more than 400
medications (by both brand and generic names)
commonly used in geriatric care settings that should
not be crushed.
276 The Consultant Pharmacist   may 2013   Vol. 28, No. 5
The pharmacist can play a vital role in making sure
staff is educated and has resources available to help them
give the myriad of new inhalers correctly. The CMS memo
provides examples of educational resources on the storage
and administration of various inhalation therapies:
• http://www.nhlbi.nih.gov/health/prof/lung/asthma/
nurs_gde.pdf
• http://www.aafa-md.org/thumbdrive.htm (under
pharmacy file-handouts)
• http://www.youtube.com/watch?v=Z_95ni8DJwU
offers a handy resource guide that shows the dosing
instructions and storage and cleaning requirements for
inhaled medications (available at www.med-pass.com).
Fluid Fiascos
One of my pet peeves is when there are a lot of different
supplements scheduled during med pass. One day I
watched a nurse giving medications in the late afternoon.
Every resident got pills, a protein supplement, a urinary
tract infection preventive supplement, and a nutritional
supplement! Most of them couldn’t drink it all, and I bet
they couldn’t eat their supper that was scheduled half an
hour later, either.
Often, staff is expected to give (and ensure the patent
drinks) one or more supplements during medication
administration. Nutritional supplements can sometimes
interact with medications or cause stomach upset that
could be attributed to medications. Additionally, staff can
become complacent with reading the amount of supple-
ment to be given (which was likely calculated by a dietitan
based on the resident’s individual needs [calculated from
height, weight, and physical activity level]) and simply
adopt a “one size fits all” approach to administering
dietary supplements. A pharmacist can serve as a liaison
to other disciplines—such as prescribers, dietary, and
nursing—to help prioritize what needs to be given during
the administration of medications, and what can be done
at other times.
 Caren McHenry Martin, PharmD, CGP, is a consultant pharmacist
A good working relationship with an easily in Greensboro, North Carolina, and a contributor to The Consultant
accessible pharmacist can help ensure that Pharmacist. Gianna Bryan, PharmD, CGP, is clinical services
nurses clarify these questions with the expertise of coordinator, Holladay Healthcare, Greensboro.
a pharmacist.
Disclosure: No funding was received for the development of this
manuscript. The authors have no potential conflicts of interest.
Time Well Spent Consult Pharm 2013;28:272-7.
Most pharmacists are not trained in pharmacy school on
© 2013 American Society of Consultant Pharmacists, Inc.
how to perform medication administration. However, All rights reserved.
consultant pharmacists’ unique knowledge of the many
Doi:10.4140/TCP.n.2013.272.
idiosyncrasies of the different drugs on the market,
coupled with an understanding of nursing home regula-
tions and the “rights” of medication administration,
provide the opportunity to partner with nursing staff
to ensure medications are given correctly. A consultant
pharmacist who takes the time to interact on a personal
level with the frontline staff to ensure they are giving
medications correctly can have a profoundly positive
impact on the facility and the individual resident. n

The Consultant Pharmacist   may 2013   Vol. 28, No. 5  277