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Medication Error. A medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention. The U.S. Food and Drug Administration (FDA) receives more than 100,000 U.S. reports each year associated with a suspected medication error.

Serious harmful results of a medication error may include:

          • Death
          • Life-threatening situation
          • Hospitalization
          • Disability
          • Birth defect

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In a nursing home, 42 CFR 483.45(f) provides that the facility must ensure that its –

(1) Medication error rates are not 5 percent or greater; and

(2) Residents are free of any significant medication errors.

Nursing homes are also prohibited from administering unnecessary drugs or drugs that would be used as a restraint.  An unnecessary drug is any drug when used –

(1) In excessive dose (including duplicate drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use; or

(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section

See also ASHP Guidelines on Preventing Medication Errors in Hospitals

And see Medication Administration Errors at the Agency for Healthcare Research and Quality

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