What are the top Long Term Care pharmacy errors, and how to correct them?


In 2005, a Gurwitz study estimated that there are 800,000 medication errors yearly in Long Term Care facilities. That number has probably risen as the Boomer generation continues to age. What are the main pharmacy errors and how can we correct them? There are three main trouble areas:

• Medication errors
• Orders not received (ONR)
• Lack of integration

The key solutions for solving these problems revolve around diligent training of pharmacy staff and the use of current pharmacy technology to track every stage. From the moment that an order comes in, a pharmacy should be able to see where that order is in the process from printing the label to putting the completed order into the tow. They should also be able to easily find out who touched the order along the way.

According to the Institute for Safe Medication Practices, there will be over 1.4 million people in Long Term Care (LTC) facilities in 2013. About one-third of these patients will be on an average of nine medications daily. Therefore it is imperative for Long Term Care facilities to address these problems early.

Medication errors

The two main errors in medication are wrong dosage and wrong medicine. Wrong dosages may be more common than you think, especially between whole tab and half-tab dosages. It is up to the pharmacist to ensure that when a label is printed and filled that the correct dosage is there.

No medical professional wants to give the wrong medicine to a patient, but mistakes do happen. With proper training and technology, medication errors can be reduced significantly. If your pharmacy is still running on paper and memory, consider upgrading your system today. You could save a life.

Current technologies now use barcode scanners that give more information about the exact timing and dosage information. This technology can also warn techs when they’re about to give the wrong dosage or medicine to a patient. This scanning procedure also keeps all the records straight, including which tech filled which prescriptions and when they were sent to the Long Term Care facility. If you are currently not using a scanning system for your labels and medications, then your risk for medication errors is high.

Orders Not Received (ONR)

Label tracking systems also reduces another major error in pharmacies called ONR or Orders not received. When a Long Term Care facility does not receive the medication they ordered it can threaten a patient’s life. The key thing is to have a way to track the entire order from start to finish. A pharmacist should be able to scan a label and know everything about that order.ONR’s can also originate from the Long Term Care facility. Having the ability to go back and show what exactly was in an order can reduce confusion and help both Long Term Care facilities and pharmacists in their training of staff. It can also identify people who need disciplinary actions.

Lack of integration

Efficiency is the name of the game for hospitals and for pharmacies. Pharmacies and Long Term Care providers should be working hand-in-hand to develop systems that allow everyone to see the current status of medication supplies. If it takes a pharmacist a half an hour to pull up an order or a nurse to report that an antibiotic is low, efficiency and patient care quality will be reduced.There are several pharmacy technology providers that have stepped in to help increase the integration between the pharmacy and the nurses and doctors. Products like AcuDose-Rx allow nurses to retrieve drugs from special cabinets that are wired to the overall pharmacy system. A nurse can pull a patient’s medication and have it all bundled right from the cabinet. The system will prevent incorrect medication from being dispensed. When supplies are getting low, a message is automatically sent to the pharmacy to fill the cabinet.


Gurwitz JH et al. American Journal of Medicine. 118(3):251–258. 2005

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