Case Study: Medication Mayhem


A common, dangerous recurring theme for seniors is medication errors. Seniors who have family or care staff looking after them are less likely to encounter medication errors and take their medications the prescribed way. I’ve spoken with many residents who don’t understand why they have been prescribed so many medications and what the medications are for.


Let's delve into this next case study which, unfortunately, happens quite frequently.

A resident and their neighbor came down for assistance with her medication. The resident’s neighbor dropped a month’s worth of pill pack medications on my desk as well as a medication bottle with another medication in it, mostly full. The bottle of medication’s expiration date was 2017, and the pill packs were from early 2019. You can imagine my surprise. The member wanted to know which medication she should take. She had recently decided to switch doctors and could not remember the last time she went to her doctor, which may have explained why she didn’t have any current medications. She "had a splitting headache and needed to take something right away."

I reviewed the medications and advised that it was not safe to take these expired medications and that I could help call the doctor to see if they will renew her medications and advise her on her headache. I was very hopeful that we could get a telehealth appointment that day. After 40 minutes on hold with the doctor’s office, they said they had not seen the resident since January and could not renew any medications without seeing her. Absolutely, this is the right call. They didn’t have any spots on their schedule for the same day but could get her in the next day.

The resident was thankful that I was able to get through and assist. Due to the long wait time on hold, the resident went back to her apartment to rest and get rid of her headache while waiting on hold and getting her appointment scheduled. When she returned to the wellness office, we discussed the importance of taking medication correctly, attending all scheduled medical appointments, and ensuring that you are taking the right medication at the right time and not letting them expire.

Unfortunately, we see these patterns over and over, a trend we are hoping to break. Residents will ration medication, share medication, and save unused medications- "just in case" and mix medications, forgetting what pills went in what bottles.


We are privileged to be the eyes, ears, and advocates for our residents, helping them get back on track to a healthier lifestyle. While the member’s neighbor meant well and certainly did the right thing by bringing her to the wellness office, she didn’t have the knowledge or tools to reach out to the doctor’s office or counsel her friend correctly on using expired medications.

We have caught many medication errors for our residents and have connected with their providers to rectify the problems. Providing better healthcare outcomes for our members and reducing costly ER visits due to medication misuse is one of the key reasons an on-site wellness program benefits all.