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Why Do Medication Errors Happen in Nursing Homes?

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Sometimes, caregivers, nurses, and physicians make mistakes when they are administering medicine to a patient. These mistakes are referred to as medication errors and may include administering the incorrect dosage, wrong medicine and even using the wrong method of administering the drug. These mistakes can have very serious health effects on the patients like weakening their immune response, causing unexpected medical complications, malnutrition and dehydration, organ failure, and even death.

Causes of medication mistakes in nursing homes

Many factors lead to mistakes in administering prescription drugs to patients, but the most notable ones include misreading medicine orders and labels, being understaffed, carelessness of staff members, poor staff training, not doing a follow-up with doctors and pharmacists, and stress on staff. In addition, the following are some of the more common types of medication errors that medical practitioners make in nursing homes:

Knowledge-based error

This occurs when the medical staff does not know that the medicine will affect the patient negatively. An example of this mistake is when the staff administers penicillin to the patient without knowing that the patient is allergic to it. This type of mistake is caused by a lack of knowledge regarding a patient’s medical history, diet, and other prescriptions among other relevant medical information.

Rule-based error

A rule-based mistake is made when the medical personnel either uses a bad rule or wrongly applies a good rule. An example of a rule-based medication mistake is when a specific drug which should be injected through the upper arm, is injected through a different route like through the thigh. Such mistakes are caused by improperly trained medical personnel, incorrect prescription directions, exhaustion or inattention of medical staff, and confusion regarding the rule.

Action-based error

These mistakes are made when the medical staff have the right information and want to do the correct thing, but they inadvertently end up making a mistake, also referred to as slips. Examples of action-based mistakes include picking up the wrong medicine from the pharmacy shelf, writing down the wrong prescription, and misreading a prescription.

Action-based medication mistakes are caused by the inattention and exhaustion of medical professionals, inattention to detail, and neglect. Unfortunately, these mistakes happen even in the best facilities, but a well-managed and staffed nursing home has systems in place to notice the mistake before it does any serious damage.

Memory-based error

Memory-based mistakes are simple mental mistakes that affect the administering of medicine to patients. An example of memory-based mistakes includes; when a nurse gives a patient medicine then forgets to record that she administered the medicine, and another nurse unnecessarily administers it to the same patient. A memory-based mistake can be avoided if a nursing home is well-staffed because the medical workers will not suffer from excessive exhaustion or lack enough time to treat each resident.


In conclusion, mistakes in administering medicine to patients can be avoided or reduced in nursing homes if the facility is well-staffed, provides proper training to medical practitioners, and has put systems in place to catch mistakes before they cause dire consequences to patients, such as cross-checking the medicine orders and the labels.

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