Medication errors, missed or delayed doses
Wrong-resident doses, missed doses and delays are well-documented risks in long-term care, especially at the administration and order-processing stages.
A HealthLink Outreach nurse visits daily, gives medications on schedule and does a wellness check. Care teams and families hear how the visit went.
Source: ISMP Canada Safety Bulletin 24(9), 2024; B.C. Residential Care Regulation, s. 68.
Late or missed pharmacy deliveries
When a delivery is late or a dose is missed, residents can go without needed medication.
Medications are delivered from the matched pharmacy and given on schedule, every day. Through our partner pharmacies, urgent and after-hours medication needs can also be coordinated when a regular delivery window is not enough.
Source: ISMP Canada Safety Bulletin 24(9), 2024 (missed or poorly timed doses).
MAR and eMAR records that fall out of step
Errors often occur when orders are entered or confirmed, or when the pharmacy system and the facility’s medication administration record are not aligned.
Partner pharmacies can support electronic or paper medication administration records, including help keeping pharmacy records and the facility MAR in step. B.C. rules already require a pharmacist to record medications on the MAR.
Source: ISMP Canada Safety Bulletin 24(9), 2024; Residential Care Regulation, s. 69.
Cycle-fill or blister-pack changes mid-cycle
When a prescriber changes a direction, the package and the MAR have to change with it. Handwritten changes on a label are not allowed, and the pharmacy must be told promptly.
A daily nurse visit can surface a packaging mismatch. Partner pharmacies handle mid-cycle and cycle-fill updates and record direction changes on the MAR after they are notified.
Source: Residential Care Regulation, s. 71; ISMP Canada (missed discontinuations and holds).
After-hours or urgent (stat) medications
When the pharmacy is closed, urgent new orders are harder to fill and easier to get wrong.
Through our partner pharmacies, urgent and after-hours medication needs can be coordinated so residents are not left waiting until the next regular delivery.
Source: ISMP Canada Safety Bulletin 24(9), 2024 (order entry when the pharmacy is closed).
Medication reviews
Regular pharmacist review helps catch interactions, duplications and medications that are no longer needed.
Partner pharmacists can provide medication reviews, following the professional and PharmaCare rules that apply to the setting — including reviews already funded for Plan B long-term care homes, and community medication reviews where a resident is eligible.
Source: PharmaCare pharmacy services; College of Pharmacists of B.C. residential-care standards.
Staff medication training
B.C. residential care rules require training for employees who store, handle or administer medications, set by the facility’s medication safety and advisory committee (which includes a supervising pharmacist).
HealthLink Outreach nurses give the daily medications, so the facility is not relying only on its own staff for that pass. Partner pharmacies can also support staff training on storing, handling and administering medications, alongside the facility’s committee. Cooking, cleaning, bathing and personal care stay with your existing care team.
Source: Residential Care Regulation, ss. 68 and 70.
Keeping families and the care team informed
Breakdowns in communication — at shift change, after a hospital return, or with families — are a common theme in medication incident reports.
Every visit follows the person’s care plan, and the care team and family hear how it went. If something changes, our nurses can connect the person to a same-day virtual doctor appointment or to the closest medical clinic in our network.
Source: ISMP Canada Safety Bulletin 24(9), 2024 (communication and family engagement).
Discontinued or expired medications
B.C. rules require the facility to return a resident’s medication to the dispensing pharmacy when it is no longer being taken or has expired.
Partner pharmacies accept discontinued or expired medications returned from the facility and can walk your team through that process. The facility’s legal duty to return them still applies.
Source: Residential Care Regulation, s. 72.
Admissions, discharges and returns from hospital
Incomplete medication histories at admission or after a hospital stay are a documented source of harm, including missed or duplicated doses.
Once care is confirmed, a nurse can start daily visits within 48 hours, and we walk you through the pharmacy switch. When a resident is admitted, discharged or returns from hospital, our partner pharmacies can help review and reconcile the medication list so the next doses are accurate.
Source: ISMP Canada Safety Bulletin 24(9), 2024 (medication reconciliation at transfers).
These sources describe risks in long-term and residential care generally. They are not a study of HealthLink Outreach or of any named facility or pharmacy. ISMP Canada, “Reporting and Learning in Ontario Long-Term Care Homes: A Multi-Incident Analysis of Medication Incidents,” Safety Bulletin 24(9), 30 September 2024. Residential Care Regulation, B.C. Reg. 96/2009, ss. 68–72.