Hands of doctor or physician recommending pills (medical prescription) to male (hands only)

Medication Error Documentation Reminder

Medication can be an important tool to help keep a person healthy. However, when doses are missed, administered incorrectly, or given to the wrong person, it can be dangerous. Below are some reminders to help avoid medication errors.

Summit DD investigated 15 instances of alleged Neglect involving medication errors in 2023.

  • 5 were due to medication delegation errors such as giving medications to the wrong person;
  • 4 were related to not properly securing medications in the home;
  • 3 for not administering medications as required; and
  • 3 due to not refilling medications timely

Alert iconCommon Causes for Medication errors (per DODD):

  • Being rushed. Staff hurrying due to an upcoming appointment, ride coming, etc. and not following medication procedures.
  • Distractions. The person passing medications was distracted because they were taking a personal call at the time.
  • Not following procedure. Employee did not complete the “right person” check and gave the person their roommate’s medications.
  • Convenience. Staff pre-set up medications in cups for convenience and administered improperly.
  • No medication on hand. A change in the prescribing doctor resulted in lapse of medication availability and no one contacted pharmacy/office for options.
  • Improperly securing medication. Medications were not secured.

Tips iconREMINDERS: What to do if there is a medication error

Per DODD, when medication errors by a med certified DD personnel are discovered, a notation should be documented in the Medication Administration Information System database (MAIS) by the employer or RN Trainer.

The notation needs to include:

  1. information regarding the type of medication error,
  2. determination of causes and contributing factors,
  3. prevention plan, training/retraining provided, and
  4. any additional measures taken or corrective action


DODD provides the following resources to assist providers with how to make these MAIS notations:

For more information or support on medication administration requirements, please reach out to Summit DD’s provider relations team at ProviderSupport@SummitDD.org

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