Preventing Medication Errors in Long-Term Care Centers
Medication errors represent one of the most serious and persistent patient safety
challenges in long-term care (LTC) centers, including nursing homes, skilled nursing facilities,
and assisted living environments. Residents in these facilities are predominantly older adults who
often suffer from multiple chronic illnesses such as cardiovascular disease, diabetes, dementia,
and arthritis. Managing these conditions frequently requires complex medication regimens
involving numerous prescriptions, increasing the risk of polypharmacy and drug interactions.
Age-related physiological changes, such as reduced renal and hepatic function, further
complicate medication management and heighten vulnerability to adverse drug events. As a
result, even minor errors in medication prescribing, dispensing, or administration can lead to
severe health consequences.
According to the Agency for Healthcare Research and Quality (AHRQ), medication-
related errors are among the most frequently reported safety incidents in long-term care settings
and are a leading cause of preventable harm among residents (AHRQ, 2022). These errors can
result in hospitalizations, prolonged illness, reduced quality of life, and increased mortality. With
the growing aging population and rising demand for long-term care services, addressing
medication safety has become an urgent public health and healthcare quality concern.
Preventing medication errors in long-term care centers requires a comprehensive and
systematic approach that integrates standardized medication management procedures,
technological interventions, staff education, effective communication, and interprofessional
collaboration to improve resident safety and healthcare outcomes.
Scope and Impact of Medication Errors in Long-Term Care
Medication errors occur at various stages of the medication-use process, including
prescribing, transcribing, dispensing, administering, and monitoring. Research indicates that a
substantial proportion of long-term care residents experience at least one medication error during
their stay, many of which are preventable. In a systematic review examining nursing home
residents, Ferrah et al. (2017) found that medication errors frequently resulted in adverse drug
events leading to hospitalization and, in some cases, death. These findings underscore the
seriousness of medication safety failures in LTC environments.
The economic and systemic impact of medication errors is also significant. Preventable
adverse drug events contribute to increased healthcare costs due to emergency room visits,
hospital admissions, and prolonged treatment. AHRQ (2022) estimates that hundreds of
thousands of adverse drug events occur annually in U.S. nursing homes alone, placing a heavy
burden on both healthcare systems and families. Beyond financial implications, medication
errors undermine trust in long-term care facilities and negatively affect residents’ physical and
psychological well-being.
Older adults are especially susceptible to medication-related harm because of altered
pharmacokinetics and pharmacodynamics associated with aging. High-risk medications, such as
anticoagulants, insulin, opioids, and psychotropic drugs, are commonly used in LTC settings and
are frequently implicated in serious medication errors. Consequently, improving medication
safety in these environments is essential for protecting a highly vulnerable population.
Causes of Medication Errors in Long-Term Care Facilities
Medication errors in long-term care centers are rarely the result of a single factor; rather,
they arise from complex interactions between human, environmental, and system-level issues.
Human factors play a major role, particularly among nursing staff who are responsible for
administering medications. High workloads, fatigue, interruptions, and time pressure increase the
likelihood of errors during medication preparation and administration. Scott-Cawiezell et al.
(2007) found that common medication errors in nursing homes included dose omissions, wrong
dosages, and administration of incorrect medications, often linked to staffing challenges and
workflow disruptions.
Environmental and organizational factors further contribute to medication errors. Poor
lighting, noisy environments, cluttered medication carts, and similar drug packaging or labeling
can easily lead to confusion and mistakes. Dilles et al. (2011) emphasized that inadequate work
environments and insufficient organizational support significantly hinder nurses’ ability to
manage medications safely. Additionally, high staff turnover and reliance on temporary or
agency staff can disrupt continuity of care and reduce familiarity with residents’ medication
regimens.
Communication breakdowns are another critical cause of medication errors in long-term
care settings. Transitions of care—such as admission from hospitals or transfers between
facilities—are particularly high-risk periods. Medication discrepancies frequently occur when
medication histories are incomplete, outdated, or inaccurately documented. AHRQ (2021)
reports that many residents enter long-term care facilities with at least one medication
discrepancy, increasing the risk of omissions, duplications, or incorrect dosing. Poor
communication among physicians, nurses, pharmacists, and caregivers exacerbates these risks
and compromises patient safety.
Strategies for Preventing Medication Errors
Standardized Medication Management Procedures
One of the most effective strategies for preventing medication errors is the
implementation of standardized medication management procedures. Clear, evidence-based
protocols for prescribing, administering, and documenting medications help reduce variability
and ensure consistency across staff members and shifts. Standardization is particularly important
in facilities with frequent staff changes, as it promotes uniform practices regardless of personnel
differences.
Designating “no interruption” or “quiet” zones during medication administration has been
shown to reduce distractions that commonly lead to errors. SkilledCare (2023) emphasizes that
minimizing interruptions during medication rounds allows nurses to focus fully on the task,
thereby improving accuracy and safety.
Technological Interventions
Technology plays a vital role in reducing medication errors in long-term care centers.
Electronic medication administration records (eMARs) replace paper-based systems and reduce
transcription errors by providing real-time, accurate medication information. Barcode medication
administration (BCMA) systems further enhance safety by verifying the correct patient,
medication, dose, route, and time before administration (AHRQ, 2022).
Automated dispensing cabinets and pharmacy automation systems also contribute to safer
medication practices by improving accuracy in medication storage and dispensing. These
systems reduce reliance on manual processes, minimize human error, and improve workflow
efficiency. When implemented effectively, technology serves as a critical safeguard within the
medication-use process.
Staff Education and Training
Ongoing education and training are essential components of medication error prevention.
Regular training sessions ensure that nurses and caregivers remain knowledgeable about safe
medication practices, high-risk medications, and updated facility protocols. Education also
reinforces the importance of adherence to safety standards and encourages vigilance in
medication administration.
Creating a culture of safety is equally important. Facilities that promote non-punitive
error reporting enable staff to report mistakes and near misses without fear of blame. This
transparency allows organizations to identify patterns, learn from errors, and implement
preventive strategies (SkilledCare, 2023).
Medication Reconciliation and Interprofessional Collaboration
Medication reconciliation is a critical strategy for preventing errors, particularly during
transitions of care. Conducting thorough medication reviews at admission, transfer, and
discharge helps ensure that medication lists are accurate and complete. Involving pharmacists in
medication reconciliation has been shown to reduce discrepancies and inappropriate prescribing
in long-term care settings (FrameworkLTC, 2024).
Interprofessional collaboration among healthcare providers further enhances medication
safety. Effective communication and teamwork between physicians, nurses, pharmacists, and
support staff improve oversight of complex medication regimens. Pharmacist-led medication
reviews are particularly valuable for identifying drug interactions, duplications, and potentially
inappropriate medications, thereby reducing the risk of adverse drug events.
Conclusion
Medication errors in long-term care centers pose a serious threat to resident safety and
quality of care. These errors are often the result of interconnected human, environmental, and
systemic factors that require comprehensive solutions. Evidence demonstrates that a multifaceted
approach—integrating standardized procedures, technological tools, staff education, effective
communication, medication reconciliation, and interprofessional collaboration—can significantly
reduce medication errors in long-term care settings. As the aging population continues to grow,
long-term care facilities must prioritize medication safety as a core component of quality care.
By implementing evidence-based strategies and fostering a culture of safety, long-term care
centers can protect vulnerable residents, reduce preventable harm, and improve overall
healthcare outcomes.
References
Agency for Healthcare Research and Quality. (2021). Medication reconciliation.
https://psnet.ahrq.gov
Agency for Healthcare Research and Quality. (2022). Medication safety in nursing homes:
What’s wrong and how to fix it. https://psnet.ahrq.gov
Dilles, T., Elseviers, M. M., Van Rompaey, B., Van Bortel, L., & Stichele, R. V. (2011). Barriers
for nurses to safe medication management in nursing homes. Journal of Nursing Scholarship,
43(2), 171–180. https://doi.org/10.1111/j.1547-5069.2011.01386.x
Ferrah, N., Lovell, J. J., & Ibrahim, J. E. (2017). Systematic review of the prevalence of
medication errors resulting in hospitalization and death of nursing home residents. Journal of the
American Geriatrics Society, 65(2), 433–442. https://doi.org/10.1111/jgs.14641
FrameworkLTC. (2024). Key strategies to improve patient safety in long-term care pharmacy.
https://frameworkltc.com
Scott-Cawiezell, J., Pepper, G. A., Madsen, R. W., Petroski, G., Vogelsmeier, A., & Zellmer, D.
(2007). Nursing home error and level of staff credentials. Clinical Nursing Research, 16(1), 72–
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