Assisted Living Medication Management: Medication Errors

With the increased needs of individuals in assisted living facilities, facilities must have the ability to manage complex medication regimens. Although medications can improve the functional status and quality of life for residents, improperly managed medications can also cause serious adverse consequences. The frequency of preventable medication errors is cause for concern.

Medication errors can include mistakes involving prescription drugs, over-the-counter products, vitamins, minerals, or herbal supplements. Medication errors can occur in a fraction of a minute, and the results can be devastating. Some points to consider in the reduction of medication errors are:

  • Question practitioner’s orders that are unclear or appear to be incorrect
  • Ensure all staff fully understand orders before administering medications
  • Avoid unnecessary distractions while administering medications
  • Provide adequate staff levels and sufficient staff time for uninterrupted medication administration
  • Ensure all staff understand and follow proper medication procedures
  • Do not allow inexperienced, untrained staff to administer medications
  • Provide accessible medication resources (i.e. drug books, pharmacy drug information)
  • Teach residents about their medications and listen to residents who question a medication
  • Don’t take shortcuts
  • If a medication error is made, never cover it up

The Wisconsin Bureau of Assisted Living’s Medication Management Initiative Workgroup defines a medication error as follows: A medication error is a preventable event resulting in the incorrect administration of a medication, or harm or potential harm to a resident. The practitioner’s written order identifies the prescribed medication, dose, time and route of administration for the resident. An error occurs when the resident does not receive a medication as prescribed/ordered by the practitioner. The definition of harm is a temporary or permanent impairment of physical or mental function which requires intervention.
Intervention may include monitoring the resident’s condition, acute medical treatment or a change in the practitioner’s orders.

Medication errors include:

  • Wrong medication – occurs when a medication is given that is not prescribed or has been discontinued or the medication label is incorrect
  • Wrong dose – occurs when a resident receives a medication in a dosage other than what was prescribed by the practitioner
  • Wrong time/omission – occurs when a resident does not receive medication at the time prescribed by the practitioner
  • Wrong route – occurs when a resident receives a medication via a route other than what was prescribed by the practitioner
  • Wrong technique – occurs when a medication is altered by crushing but should not be crushed, not given with or without food as prescribed, incorrect timing between doses of eye drops, ear drops, nose drops, inhalers, etc.

Relevant Regulations

Adult Family Home (AFH):
Wis. Admin. Code § DHS 88.07(3)(e)1
Wis. Admin. Code § DHS 88.10(3)
Wis. Admin. Code § DHS 88.10(3)(q)

Community-Based Residential Facility (CBRF):
Wis. Admin. Code § DHS 83.32(3)(h)
Wis. Admin. Code § DHS 83.37(1)(k)1
Wis. Admin. Code § DHS 83.37(1)(k)2

Residential Care Apartment Complex (RCAC):
Wis. Admin. Code § DHS 89.13(21)
Wis. Admin. Code § DHS 89.13(22)
Wis. Admin. Code § DHS 89.34(16)


Last Revised: March 2, 2018