Recommendations to Reduce Medication Errors in Non-Health Care Settings

Background

Medications are often stored and administered in a variety of non-health care settings. These settings include:

  • Elementary and secondary schools
  • Child day care centers
  • Summer camps
  • Adult day service centers (adult day care)
  • Group homes for the developmentally disabled (mentally retarded)
  • Assisted living/Residential care
  • Board and care homes
  • Jails (city and county)
  • Prisons (state and federal)

In all these settings, employees frequently are responsible for handling and administering prescription and over-the-counter medications to clients or residents. Some organizations may employ licensed health professionals to directly manage the medication administration process. However, many of these settings have no licensed health professionals involved.

Without adequate safeguards and supervision, medications present significant risks. Medication errors result if doses of medication are omitted, or if medication is administered to the wrong person, or given in the wrong dose. Controlled medications (e.g. Ritalin, morphine) may be stolen or diverted.

Settings in which these activities are conducted often are regulated and/or licensed by the state in which they are located, but those requirements and oversight vary substantially from state to state. Where state licensure laws apply to a setting, follow the implementing regulations and use these recommendations as supplementary guidance, as appropriate.

Anecdotal reports and results of state licensure surveys indicate that medication errors can be a significant problem in these settings. In the absence of licensed health professionals, and without adequate training for personnel involved with medications in these settings, medication errors often go undetected or unreported.

The National Coordinating Council for Medication Error Reporting and Prevention has developed these recommendations as guidance to non-health care settings to help ensure protection of clients, residents, and others who must depend on assistance for medication management in these settings. These recommendations apply to non-health care settings regardless of whether licensed health professionals are involved in managing medications.

Recommendations for Non-Health Care Settings

  1. Where medications are stored and administered to individuals, written policies and procedures should address the following:
    • Acquisition of medications (e.g., from parents, caregivers, pharmacies)
    • Documentation of medication order from licensed practitioner when applicable
    • Specification of which personnel are allowed access to medications and allowed to administer medications to students, clients or residents
    • Labeling and packaging of medications managed for students, clients or residents
    • Storage of medications, including medications that may require refrigeration
    • Secure storage and accountability of controlled drugs
    • Limitations on the type(s) of medications permissible for use or storage in the organization
    • Administration of medications (including double-checking by another staff person when feasible)
    • Documentation of medication administration
    • Documentation and reporting of medication errors and adverse drug reactions
    • Disposition of medications that are no longer needed or in use
  2. Where medications are stored and administered, training should be provided to personnel with responsibilities related to medication management. The training should correspond to the written policies and procedures, and the person's scope of duties associated with medications.
  3. Where controlled medications are stored and/or administered, safeguards should be in place to prevent and detect theft and diversion of controlled drugs.
  4. Encourage the reporting of medication errors to appropriate state and national medication error reporting programs. These medication error reports may be used to identify significant trends or patterns that can lead to improved quality and safety of health care, and to teach others how to prevent similar errors.
  5. When a medication error occurs, evaluate possible causes in order to improve the facility's system for medication management and to prevent future errors.

© 1998 - 2007 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.

Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.

Adopted: 
June 20, 2003
Revised: 
February 27, 2007