Medication Errors and Medication Overdoses

A recent Massachusetts study by researchers found that each month one out of every ten nursing home residents suffers a medication-related injury.

Common medication errors in nursing homes include:

• Dispensing the wrong medication to a resident
• Missed dosages and then sometimes the "doubling up" of those dosages when the error is noticed
• Incorrect dosages, due to transcription errors or nursing error

Unfortunately, the more medications that a resident is taking increases the likelihood that an error will occur. Recent Medicaid figures report that 68% of long-term care patients receive 9 or more prescription drugs, and 32% receive 20 or more prescription medications.

A report entitled "Incidence and Preventability of Adverse Drug Events in the Nursing Home Setting,", published in the August 1, 2000, issue of the American Journal of Medicine, found that medication errors in nursing homes are common and often preventable.

Current Problems in Medication Administration

The popularity of use of pain patches as a means of delivering pain medication has sparked controversy recently due to the large number of overdoses which have occurred in recent years and has prompted the FDA to issue a health advisory on safe usage. A pain patch works similarly to a nicotine patch in that it delivers powerful pain medication through the skin on a continuous time-release system. One pain patch can continue to deliver pain medication for up to 72 hours. Fentanyl is an opium-like substance that is up to 100 times stronger than morphine. Duragesic is a brand name for Fentanyl.

In 2005, the FDA ordered that Duragesic labels include a black box warning, which calls attention to the risks of using the patch and the signs of fentanyl overdose. The new labeling includes information on respiratory and central nervous system problems and drug interactions that could occur when using fentanyl.

Our office is currently handling two cases of medication overdose which, tragically, ended in the deaths of both residents. One resident died after having two Duragesic patches placed upon her within a 72 hour period (the second was placed and the first was never removed). The second resident died after having had three Fentanyl patches in place at the same time.

The information provided on this site relative to medication errors and medication overdoses in a nursing home setting is meant as a brief overview. Specific Federal and State laws and regulations apply and each case is unique and fact-intensive.