Types, prevalence, and potential clinical significance of medication administration errors in assisted living.

Assisted living (AL) settings increasingly serve persons who previously would have lived in a skilled nursing facility (SNF), offering a more-homelike and less-restrictive residential option at lower cost.1–4 With higher acuity, many AL residents have multiple chronic health conditions, increasing the need for ongoing monitoring and management. Core values in AL include choice, privacy, independence, and the potential to age in place.3,5,6 Although ALs cost less and provide less-institutional environments, these elements are offset by less professional oversight and the potential risk for negative health outcomes because of the need for more intensive health monitoring. A critical issue in AL is striking the appropriate balance between freedoms and risks for residents, staff, and the settings themselves.7 Nationwide, AL residents are a frail, older population with multiple chronic health problems. More than half are aged 85 and older, approximately 25% have significant cognitive impairment, and 77% receive help with medications. 2 Estimated medication use ranges from 3.8 to 6.2 regularly scheduled daily medications,8–11 higher than average medication use by older adults in the community (average 2.7–3.9) and lower than use in SNFs (average 8.9).12 Furthermore, there is a high prevalence of the use of several groups of high-risk medications in AL (e.g., psychotropics, cardiovascular agents, anticoagulants).8–11,13 In addition to multiple comorbidities and complicated medication regimens, this population experiences age-related changes in pharmocokinetics and pharmacodynamics that increase the potential for adverse drug events (ADEs).12,14 Unlike SNFs, where licensed nurses are engaged in medication administration, medications in AL are managed primarily by unlicensed assistive personnel (UAP), with limited professional involvement.15,16 Compounding the issue are high UAP turnover in AL settings17 and few structures and processes to monitor quality in medication management. 18–20 The role of the registered nurse (RN) in AL is evolving in relation to AL regulations and nurse practice acts.7,15,16,21 Medication management is one of the three top quality-of-care concerns in AL.18 Medication safety research in AL is in an early stage, with limited information about medication profiles10,22 and error rates.23 Medication administration errors are defined as “any difference between what the patient received or was supposed to receive and what the prescriber intended in the original order.”24 The most widely accepted method of assessing medication errors is a standardized approach, including direct observation of medication administration, chart review of medication orders, and identification of discrepancies between observed and expected administration. 25,26 Using this method, observers are able to identify errors that escape the awareness of the person administering the medication, and the effect of the observer on the observed has been determined to be insignificant.27 One study25 compared methods and concluded that observation with chart review is the most sensitive approach; of 2,557 doses observed in hospitals over 7 months, investigators detected 300 errors using the observation method, 34 using chart review, and one according to incident report, yielding error rates of 11.7%, 0.7%, and 0.04%, respectively.24 Using the observational and chart review method in a study of 36 hospitals, the overall error rate of licensed staff was reported as 19%.26 Observational research of medication administration errors in long-term care is in its earliest stages. Using the method described above, one study28 compared error rates of nursing home personnel of different levels and reported the following error rates: RN, 34.6%; licensed practical nurse (LPN), 40.1%, and certified medication aides, 34.2%. In the only study of medication errors in AL, the overall rate was 3.6%,23 although this study used a limited methodological approach that consisted only of observations and did not include chart review to identify intended prescription, thus likely underestimating the error rate. The purpose of this article is to describe the types, prevalence, and potential clinical significance of medication administration errors made by unlicensed personnel in AL.