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According to the AARP, Seniors on average take more than 5 different drugs over the course of a year. As a result, the proper management of medications is a high priority in nursing homes. Unfortunately, administering wrong medication and overdosing patients are frequent forms of nursing home error in poorly managed and operated nursing homes.

Medication mismanagement can take several forms: In understaffed nursing homes, overworked nurses may make careless mistakes. As a result, drugs prescribed to one resident may be inadvertently administered to another resident, running the risk of dangerous drug interactions and side effects. Furthermore, some drugs require consistent use in order to be effective and safe. Skipping doses may render the medication ineffective.

A 2006 report from The Institute of Medicine for the National Academy of Science found that preventable medication errors cause harm to 1.5 million people a year at a cost of at least $3.5 billion in extra medical costs. According to the Institute of Medicine National Academy Press, "medication errors account for approximately 1 out of 131 outpatient and 1 out of 854 inpatient deaths". According to a 1995 Journal of American Medical Association (JAMA) study, 39% of medication errors occur during prescribing; 12% occur during transcribing at the pharmacy; 11% occur during compounding at the pharmacy, and 39% occur during administration.

Confusion caused by similar drug names accounts for up to 25 percent of all errors reported to the Medication Error Reporting Program, operated cooperatively by U.S. Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP). In addition, labeling and packaging issues were cited as the cause of 33% of errors, including 30% of fatalities, reported to the program. Much of this is caused by the facility or supplier looking to cut costs by constantly searching for "bargain" medicines, resulting in inconsistent packaging and tablets.

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