When medication administration does not match a provider order, it is considered a reportable medication error. This includes the dose, route, timing/frequency, and other required monitoring/parameters. The Centers for Medicare & Medicaid Services (CMS) considers the following to be medication errors:

• Ordering the wrong medication
• Dispensing the wrong medication
• Administering the wrong medication
• Administering medication via the wrong route
• Administering medication at the wrong time or frequency
• Administering the wrong dose

An omitted dose is an unintended missed dose. When a participant does not receive a scheduled medication that was ordered by the provider and there is no documented clinical reason to hold it (for example, the order includes hold parameters that were met, a provider-directed hold/discontinue occurred, or the medication was appropriately withheld based on the written order). CMS recognizes errors of omission as reportable when a participant was expected to receive the medication, but it was not administered as ordered due to:

• Staff oversight or workflow breakdown
• Documentation or Medication Administration Record (MAR) errors
• Pharmacy access, fill, or delivery issues
• Order-to-MAR mismatch or unclear order instructions (e.g., missing parameters, frequency, or PRN (as needed) criteria)

A missed dose may also occur because the participant refused the medication. When a refusal is documented, this is an intentional non-administration and is not an omitted dose. Refusals are still important to follow up on—partner with the participant (and caregiver, when appropriate) to understand what matters most and what is getting in the way (for example, side effects, swallowing difficulty, beliefs, or regimen complexity). As needed, coordinate with nursing/pharmacy and update the regimen (e.g., adjust timing, change formulation, or discontinue). Document the refusal, assessment, counseling, and any order changes in the Electronic Medical Record (EMR).

Why Reporting Medication Administration Errors Matters

Medication error reporting supports participant safety and helps our Interdisciplinary Team (IDT) identify gaps, take timely corrective action, and continuously improve care.

Avoiding Common Medication Administration Errors

• Start with the Five Rights. Clear, complete orders (dose, route, frequency, and practical timing windows) help the team carry them out consistently:
  • Right person
  • Right medication
  • Right dose
  • Right time and frequency
  • Right route
• Build safety into the order when needed: include hold parameters and required monitoring (e.g., vitals, labs, renal dosing) and confirm updates are reflected on the MAR.
• For PRN medications, write clear indication, dose, frequency, and any assessment criteria—so nursing can document both the reason and the response.
• During transitions of care (new starts, dose changes, hospital discharge), communicate changes early and clearly with nursing and pharmacy to prevent missed doses, duplications, and delays.
• Address adherence barriers with participant-centered counseling (side effects, cost/access, health literacy, swallowing issues) and simplify regimens when feasible.
• Follow up on unavailable medications promptly (prior authorizations, alternatives, emergency supply) and close the loop with pharmacy and the care team.
• Ensure appropriate follow-up for efficacy and adverse effects (including ordering and reviewing monitoring labs when indicated).
• Reconcile medications routinely (orders, pharmacy profile, and MAR) and document clinically indicated changes and communications in the EMR.

সূত্র:

PACE Quality Data Monitoring & Reporting Guidance, Centers for Medicare and Medicaid Services (CMS), January 2024