How to Identify and Report Elderly Medication Mistakes

Every year, over 250,000 medication errors happen in U.S. nursing homes - and most go unreported. For seniors taking five or more drugs, the risk isn’t just high - it’s life-threatening. A 78-year-old with heart disease, diabetes, and arthritis might be on eight different pills. One wrong dose, one missed timing, one duplicate prescription - and they could end up in the hospital, or worse. The problem isn’t always negligence. It’s system failure. But families and caregivers don’t need to wait for institutions to fix it. You can spot these mistakes. And you can report them - the right way.

What Counts as a Medication Mistake in Seniors?

A medication error isn’t just giving the wrong pill. It’s any preventable mistake that harms someone while they’re taking medicine. For older adults, these mistakes happen in four main ways:

• Wrong dose - too much or too little. This is the most common error. Over 42% of nursing home errors involve incorrect dosing, especially with blood thinners, diabetes drugs, or painkillers like acetaminophen.
• Wrong time - giving medication hours late or too early. Blood pressure pills taken at night instead of morning can cause dangerous drops in pressure.
• Wrong drug - handing someone a pill meant for another resident. This happens more often than you think, especially when staff are rushed.
• Wrong route - swallowing a pill meant to be applied as a patch, or injecting a liquid meant for oral use.

But there are subtler errors too. Giving expired meds. Not checking for drug interactions. Prescribing a drug on the Beers Criteria list - like diphenhydramine (Benadryl) or certain sleeping pills - that the American Geriatrics Society says should be avoided in seniors because they cause confusion, falls, or memory loss. In fact, 43.8% of Medicare beneficiaries get at least one inappropriate prescription every year.

How to Spot a Medication Mistake

You don’t need to be a nurse to catch errors. Start with the Five Rights:

1. Right patient - Is this pill really for your loved one? Check the name on the label against their ID bracelet or chart.
2. Right drug - Does the name match what the doctor ordered? Watch for brand names vs. generics. Acetaminophen is Tylenol, but if they’re also on Percocet, they’re getting the same drug twice - a silent overdose risk.
3. Right dose - Does the pill look right? A 5mg tablet shouldn’t be twice the size of a 1mg one. Use a pill organizer with clear labels.
4. Right route - Is this supposed to be swallowed, placed under the tongue, or applied to the skin? Don’t assume.
5. Right time - Is this being given at the same time every day? Some meds must be taken with food, others on an empty stomach.

Also check for polypharmacy - five or more medications. The risk of error jumps from 13% with two to four drugs to over 57% with eight or more. Ask: “Is every pill here still needed?” Many seniors are on drugs from past conditions that no longer apply.

Look at the pill bottles. Are there expired dates? Are there duplicate prescriptions from different doctors? Are there pills labeled “PRN” (as needed) that are being given daily? These are red flags.

What to Do When You Find a Mistake

Don’t wait. Don’t hope it was a one-time thing. Act fast.

If it’s an emergency - your loved one is drowsy, confused, having trouble breathing, or collapsed - call 911 immediately. Then call the National Response Center at 1-800-332-1088 to report a life-threatening incident.

If it’s non-emergency - like a missed dose, wrong pill, or suspected duplication - follow these steps:

1. Document everything. Write down the date, time, medication name, dose, who gave it, and what happened. Take a photo of the pill bottle if possible.
2. Speak to the nurse or pharmacist on duty. Ask calmly but firmly: “Can we review this? I’m concerned this might be an error.” Many staff will admit mistakes if approached without blame.
3. Request a medication reconciliation. Ask for a full review of all prescriptions - including over-the-counter drugs and supplements. This should be done at every care transition (hospital discharge, new nursing home admission, etc.). Dr. Lucian Leape says this single step can prevent 67% of adverse events in seniors on five or more meds.
4. Notify the prescribing doctor. Call their office. Say: “I believe my loved one may have received an incorrect dose of [medication]. I’d like to confirm the correct regimen.”

How to Report It Officially

Reporting isn’t about getting someone in trouble. It’s about fixing the system.

There are two main paths:

1. Use the Facility’s Internal Reporting System

Every nursing home is required to have a medication error reporting form. Ask for it. It should ask for:

• Resident name and ID
• Date and time of error
• Type of error (prescribing, administration, monitoring, etc.)
• Potential severity (using NCC MERP Index - categories E to H mean serious harm or death)
• Contributing factors (staff shortage? poor labeling? no double-check?)

Insist on a copy of the report. If they refuse, say: “I’m requesting this under the Long-Term Care Ombudsman Program guidelines.”

2. Report to the State Long-Term Care Ombudsman

This is your most powerful tool. Ombudsmen are independent advocates funded by the federal government to protect nursing home residents. They have legal authority to investigate.

Call 1-800-677-1116 or visit ltcombudsman.org to find your state’s office. You don’t need to be the family member - any concerned person can report. Provide your documentation. Ombudsmen resolve 68.4% of reported cases within 72 hours.

3. Report to the FDA MedWatch Program

If the error caused serious harm - like a hospitalization, fall, or allergic reaction - report it to the FDA. This helps track nationwide patterns. Go to www.fda.gov/medwatch and file a report. You can do this anonymously.

Why Most Errors Go Unreported - and How to Beat the System

Families often stay quiet because:

• They’re told, “It was just a one-time mistake.”
• They fear retaliation - like worse care or being kicked out.
• They don’t know how to report.

But here’s what the data shows: 83.6% of families who reported errors faced initial denial. 57.2% were told the resident was “confused” or “noncompliant.” But when families threatened to contact the ombudsman, 92% of facilities immediately corrected the issue.

Don’t be afraid to escalate. You have rights. Federal law requires facilities to investigate and report all errors. If they don’t, they risk fines of up to $10,000 per unreported serious error under the 2023 Nursing Home Reform Act.

What’s Changing - and What’s Working

The system is slowly improving. By 2025, all nursing homes must use electronic medication administration records (eMAR). These systems scan barcodes on pills and wristbands - reducing errors by up to 86%. Some facilities now use AI tools like MedAware that flag dangerous drug combinations before they’re prescribed.

But technology alone won’t fix this. The biggest cause of errors? Staff shortages. In many nursing homes, one aide cares for 20+ residents. No one has time to double-check. That’s why your vigilance matters.

Even small actions help. If you visit daily, ask: “Did they take their meds today?” Watch how they’re given. Ask to see the medication log. Bring your own pill organizer. Keep a written list of every drug your loved one takes - including vitamins and supplements - and update it monthly.

Final Checklist: Your Action Plan

• ✔️ Keep a current list of all medications - name, dose, purpose, and schedule.
• ✔️ Check pill bottles for expiration dates and duplicates.
• ✔️ Ask for a full medication reconciliation at every care transition.
• ✔️ Use the Five Rights every time you see meds given.
• ✔️ Document any suspicious behavior - time, person, medication, reaction.
• ✔️ Report to the ombudsman if the facility denies or ignores your concerns.
• ✔️ Call 911 and the National Response Center if there’s a life-threatening reaction.

Medication errors in seniors aren’t inevitable. They’re preventable. But they won’t stop unless someone speaks up. You don’t need to be a doctor. You just need to be observant - and brave enough to ask, “Why?”