Managing Medication Error Rates in PACE Pharmacy Services

By definition, a medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm. Medication errors may occur at any point in time from prescribing to the PACE pharmacy dispensing the medication to administration. The Institute of Safe Medication Practices (ISMP) estimates that 7,000 deaths occur annually in the United States from preventable medication errors. The reality of medication errors is that they are possible in all care settings, including the home. Two of the most challenging aspects of medication errors in the home setting—and faced by PACE pharmacy services providers—are detection and prevention. Medication errors are an important topic in PACE pharmacy because of the Level 1 reporting guidelines, which require quarterly reporting of medication administration errors.  Reportable errors are errors without an adverse effect that occur due to a violation of a physician’s order. This includes errors made by the PACE organization, an individual or entity that is contracted with the PACE organization, or a participant or caregiver. Reporting includes the date, location, type, contributing factors, and actions taken.

PACE Pharmacy Services: Common Risks for Medication Errors

In the following paragraphs, we will review common risks for medication errors, focus areas for medication error prevention, and specific considerations for medication administration error prevention in the at home setting. As mentioned previously, medication errors can occur at any point in time from prescribing through administration of a medication. There are several common risks that have been shown to increase the potential for medication errors: Polypharmacy is potentially the strongest risk factor for medication errors. Nearly one-third of adults in the United States take five or more medications. This number increases as we age. The larger the number of medications that a patient is prescribed, the higher the potential for medication errors. Avoiding overprescribing and controlling the duration of therapy are two important considerations for keeping medication totals at an acceptable level. Health literacy is another common risk factor. It’s imperative for participants to have an understanding of what medications they’re taking, why the medications are being prescribed, and when and how the medications should be taken. Medication adherence and proper administration are less likely when participants don’t understand what they are taking and why it’s important for their health and well-being. High risk medications are an identified list of medications that can cause significant harm if used in error. This includes medications that may have dangerous adverse effects; look-alike/sound-alike medication that could be interchanged during the ordering, transcribing, or dispensing process; or Beers list medications, which may be potentially inappropriate for use in the geriatric population. Minimizing the use of medications in this group unless absolutely necessary can potentially reduce the risk for medication errors.

PACE Pharmacy Services: Focus Areas for Medication Error Prevention

There are five basic focus areas for medication error prevention, including:
  1. Prescribing/Ordering, which includes the prescriber selecting and dosing the medication appropriately for the participant
  2. Transcribing, which is getting the original order accurately to the pharmacy either verbally, in writing, or electronically. As we move to a more electronic and automated world, there are new considerations for accurate transcribing to consider.
  3. Dispensing, which is the PACE pharmacy interpreting and filling the order accurately and as written by the prescriber
  4. Administration, which could involve a nurse, participant, or caregiver. This includes taking the medication in the manner in which it was prescribed.  
  5. Monitoring and Reporting, which is appropriately following up with the participant to check on progress and using skills to determine if medications are being taken properly. Early detection is important for preventing more severe issues.
While prescribing and transcribing have historically been areas where the majority of errors occur, errors with administration are increasing both in the inpatient and at-home settings. It is estimated that one out of every three medication errors is caused by lack of knowledge of either the medication or the patient. [Tweet “Learn 5 keys to preventing #medicationerrors among #PACE participants in the home environment.”]

PACE Pharmacy Services: Prevention of Medication Errors in the At-home Setting

The following considerations may provide assistance with reducing medication errors in the at- home setting:

Improved Care Coordination

Improving care coordination includes improving communication channels and opportunities between players of the healthcare team, such as doctors, nurses, and pharmacists.  Coordinated and enhanced communication is essential to optimal healthcare management.

Patient/Caregiver Engagement

Patient and caregiver engagement is centered on finding the most effective ways possible to interest a participant and include his or her caregiver support system. Tap into the participant’s interests and skill levels. Think outside of the box as it is definitely not one size fits all.

Focus on Transition of Care

Two-thirds of medication errors are believed to occur during transitions of care. When a patient is transitioning between care settings, this is a special opportunity for enhanced care coordination, communication, and patient/caregiver engagement to ensure all parties are on the same page and working from the same plan.

Health Literacy Education

Health literacy education is designed to ensure the participant understands his or her therapies, taking into consideration hearing, vision, or physical impairments, language barriers, and/or the ability to understand written text.


Labeling can provide medication and educational materials in a manner that is clear and easily understood by the participant. In addition to words, consider pictures, symbols, or colors to help create an easily understood administration plan.

Embracing and Incorporating Technology

Technology does not have to be complicated. Consider assistive devices such as phone calls, text messages, or machines to remind participants when to take medications and to confirm which medications need to be taken. This can also be used as follow-up confirmation for the care team or family support team. Medication errors can be overwhelming at times. As medication errors occur, thorough documentation and root cause analysis of when, where, and how a breakdown occurred will help develop a manageable solution that will reduce the risk of the same error occurring in the future. ISMP and the Agency for Healthcare Research and Quality are great resources for additional information and ideas about medication error awareness and reduction strategies. Grane Rx offers innovative PACE pharmacy solutions designed to prevent medication errors and improve adherence. Put our PACE pharmacy services to work for your PACE center today by calling (412) 449-0504 or emailing]]>

Find out how we can help with your PACE pharmacy needs?