Medication Errors in Michigan: What Patients and Families Should Know

Medication errors happen when a drug is prescribed, dispensed, administered, or monitored in a way that does not match the patient’s needs or the intended plan of care. Some errors cause short-term side effects, while others lead to serious injury or death, especially when dosing, interactions, allergies, or organ function are missed. Understanding how medication errors happen can help patients and families make sense of what went wrong and what questions to ask next.

Medication is intended to support recovery, manage symptoms, or prevent complications. When a medication causes harm instead, most people are left trying to understand whether the reaction was unavoidable, unexpected, or the result of a mistake somewhere in the process.

This page is designed to explain medication errors in clear, practical terms. It outlines how these errors commonly occur, the types of harm they can cause, and how they are typically identified after treatment. The goal is not to assign blame, but to help patients and families better understand what may have happened and how medication safety is evaluated in healthcare settings.

Buchanan Firm brings more than 85 years of combined experience in serious injury and malpractice cases, and the firm is led by the former President of the Michigan State Bar. When questions involve complex medication decisions, we have fast access to trusted, independent medical experts who help us review records and explain what the timeline shows.

How Medication Errors Happen

Medication errors usually happen at predictable points in the medication process. The safest way to understand what might have gone wrong is to follow the medication’s path from order to outcome and look for a mismatch at any step.

Ordering the medication

This is where the drug, dose, route, and timing are chosen. Problems can show up when a medication is not adjusted for age, weight, kidney or liver function, or when allergies and current medications are incomplete or outdated.

Entering and transmitting the order

Orders often move through electronic systems and across teams. Selection mistakes in drop-down menus, unclear instructions, and small documentation gaps can change what was intended.

Dispensing and preparing the medication

A pharmacy or medication unit prepares what was ordered. Look-alike names, similar packaging, and different concentrations of the same drug can create mix-ups, especially when the label and the actual concentration do not match what the patient should receive.

Giving the medication

This step is vulnerable to timing problems, missed identity checks, and handoff confusion. Even when the order is correct, harm can occur if the medication is given too soon, too late, too frequently, or by the wrong route.

Monitoring the patient’s response

Some medications require close observation and follow-up labs or vitals. If early warning signs are missed, a tolerable issue can become a serious complication.

Medication errors are rarely the result of a single failure. They more often reflect breakdowns in coordination, verification, or follow-through within a complex care environment.

Common Types of Medication Errors

Medication errors tend to fall into a few common patterns, which makes it easier to know what to look for in the records. The most common types include:

Drug selection errors: A patient receives a different medication than intended. This can occur when drugs have similar names, packaging, or labeling, or when the wrong option is selected from a medication list.
Dosage and strength errors: The amount given does not match what the patient should receive. This may involve an incorrect unit of measurement, an unintended concentration, or a failure to adjust dosing based on patient-specific factors.
Timing and frequency errors: Medication is given too early, too late, too often, or not often enough. For certain drugs, timing affects how the body absorbs or tolerates the medication.
Wrong-patient errors: Medication intended for one patient is administered to another. These errors most often occur in settings where multiple patients receive treatment in close proximity.
Interaction-related errors: A medication is prescribed or administered without accounting for how it may interact with other drugs, supplements, or existing medical conditions.
Omission errors: A required medication or dose is skipped entirely, either unintentionally or because the need was not recognized at the time.

Each of these error types can occur independently or in combination. Understanding the category helps narrow what records, orders, and observations matter when reviewing what happened.

Medication Errors in Hospitals and Care Facilities

Hospitals and care facilities manage medication differently than outpatient settings. Patients are often receiving several drugs at the same time, their condition may change quickly, and responsibility for care is shared across multiple providers and shifts. Medication decisions are rarely static, and orders can be updated, paused, or adjusted as treatment progresses.

Because care is continuous, information moves constantly. Medication orders may be entered electronically, reviewed by a pharmacy, carried out by nursing staff, and revisited by physicians as new symptoms or test results appear. Each handoff introduces the possibility that details are missed, misunderstood, or applied out of sequence.

Timing also plays a role. A dose that was appropriate earlier in the day may no longer be appropriate later, particularly if a patient’s kidney function, breathing, or level of consciousness changes. In these environments, medication safety depends not just on the original order, but on how closely a patient is observed after the medication is given.

Hospitals use standardized workflows to manage a high volume of medication orders, but those workflows can break down when a patient’s condition is changing quickly. These systems are necessary, but they are not designed to anticipate every patient-specific variable.

When care becomes fast-paced and highly coordinated, it can be harder to slow down and reassess whether a medication plan still fits the individual patient in front of the provider.

This complexity helps explain why medication errors in hospitals and care facilities are often tied to coordination and follow-through, rather than a single isolated action.

What Harm Can Result From a Medication Error

The effects of a medication error can vary widely. Some people experience temporary symptoms that resolve once the medication is adjusted or stopped. Others are left dealing with more serious complications that change the course of their recovery or long-term health.

In milder cases, a patient may notice unexpected side effects such as dizziness, nausea, confusion, or fatigue. These symptoms can still be disruptive, especially if they delay healing or prolong a hospital stay, but they often improve once the issue is identified.

More serious harm can occur when a medication affects critical body systems. Certain drugs can interfere with breathing, blood pressure, heart rhythm, or kidney function. When this happens, the body may not get enough oxygen, organs may be placed under stress, or normal bodily regulation can be disrupted. These effects sometimes develop gradually, which makes them harder to recognize in busy care settings.

In the most severe situations, medication errors can lead to lasting injury. Prolonged oxygen deprivation can damage the brain. Toxic levels of a drug can injure internal organs. Some patients experience permanent disability or require ongoing medical care as a result of complications that began with a medication mistake.

Not every bad outcome points to the same cause, so the type of harm and the timing matter. The type of harm depends on the medication involved, the dose, the patient’s underlying health, and how quickly the problem is recognized and addressed.

Helpful External Resources

These links are educational, non-commercial, and focused on medication safety and error information.

CDC: Medication Safety Resources

Patient-focused info on preventing medication-related harm (tips, facts, prevention resources).

AHRQ PSNet: Medication Errors and Adverse Drug Events

National health safety primer explaining what medication errors and ADEs are, how they occur, and key definitions.

NCC MERP — Types of Medication Errors

A national patient-safety resource that explains common hospital errors, including discharge-related failures, in plain language designed for patients and caregivers.

Michigan Pharmacists Association — Patient Safety Resource Center

Michigan association offering patient safety links and drug safety info (general medication safety education).

Institute for Safe Medication Practices (ISMP)

National medication-safety nonprofit with guidance on reducing errors (educational and prevention oriented).

These resources can help you better understand what a safe discharge should include and why breakdowns during this transition can lead to serious harm.

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Real Case: A Fatal Opioid Medication Error

Buchanan Firm represented the family of Jim, a 45-year-old Army veteran and father of twin boys from Traverse City. Jim went to the hospital with severe abdominal pain and was diagnosed with acute pancreatitis, a condition that is painful but often treatable with proper care and monitoring. What should have been a hospital stay focused on managing his condition instead ended in a fatal medication error.

During his admission, Jim was given repeated doses of the powerful opioid hydromorphone (Dilaudid) for pain. Jim was opioid-naïve, meaning his body was not accustomed to narcotic medications, making careful dosing and close monitoring essential. Over the course of the day, hospital staff administered escalating amounts of hydromorphone and eventually placed him on a patient-controlled analgesia (PCA) pump, allowing the drug to be delivered continuously and on demand.

But staff did not closely monitor his response. The doses were increased beyond recommended levels, and basic safety checks were missed. His oxygen levels began to drop, and warning signs of opioid toxicity appeared, including sleepiness (sedation) and slow, shallow breathing (respiratory depression). Despite these warning signs, the medication continued infusing. Overnight, Jim suffered severe oxygen deprivation, stopped breathing, and died in the hospital.

Cases like Jim’s illustrate how medication errors often occur, not because a drug is inherently dangerous, but because the safeguards protecting the patient are not followed. Strong opioids require constant attention to breathing, oxygen levels, and level of consciousness. When those signs are missed or ignored, harm follows quickly.

Attorney Rob Buchanan often tells families that medication safety depends on vigilance at every level of care.

“Hospitals have systems in place specifically to prevent medication injuries like this. When powerful drugs are being given to a patient, medical providers have to slow down, watch the patient closely, and respond to warning signs. If that vigilance breaks down, a medication meant to relieve pain can instead end a life.”
– Leslie Caliguri

What Patients and Families Can Do

Medication safety should never fall on the patient alone, but asking a few questions can help prevent mistakes:

Ask what medication you are receiving and why it is being used
Tell providers if you do not normally take opioid or sedating medications
Ask how medical staff will monitor breathing, oxygen levels, and drowsiness
Speak up if the patient becomes overly sleepy, confused, or difficult to wake

Most medication errors are preventable. Jim’s case is a reminder that powerful medications require constant attention, and when that attention lapses, the consequences can be deadly.

How Medication Errors Are Identified After Treatment

Medication errors are not always obvious the moment they occur. In many cases, concerns arise only after a patient’s condition changes, unexpected symptoms appear, or recovery does not follow the anticipated course. Identifying what happened usually requires looking back at the sequence of care rather than focusing on a single event.

The review process starts with records. Medication orders, administration logs, pharmacy dispensing information, and nursing notes are examined to understand what was ordered, what was given, and when those steps occurred. Timing matters, especially when symptoms appear shortly after a medication is introduced, changed, or combined with another drug.

Clinical context is also important. Reviewers look at the patient’s underlying health, existing diagnoses, and other medications to determine whether a reaction fits what would normally be expected or whether something falls outside typical risk patterns. Lab results, vital signs, and monitoring data can provide clues about how the body responded over time.

Because medication management involves multiple steps and providers, the focus is on continuity. The goal is to see whether information was consistently carried forward as care progressed and whether adjustments kept pace with changes in the patient’s condition. This kind of review is meant to establish clarity, not assumptions, and often reveals whether harm resulted from an unavoidable reaction or from a breakdown somewhere along the medication process.

What medication records should I ask for if I’m trying to understand what happened?

If you’re trying to make sense of a medication timeline, the most helpful documents are the ones that show what was ordered, what was actually given, and what the patient’s condition looked like around those doses.

Here are the records patients and families most often request:

Medication Administration Record (MAR or eMAR):

A time-stamped log showing what medication was given, when it was given, and by which route.

Physician orders and order changes:

The original medication order plus any edits, holds, discontinuations, or dose adjustments.

Pharmacy dispensing records:

What the pharmacy prepared and supplied, including strength and concentration.

Nursing notes and vital signs:

Often the best context for how the patient looked before and after a dose.

Lab results tied to medication monitoring:

For certain medications, labs help show whether drug levels, kidney function, electrolytes, or clotting markers were changing.

Discharge medication list and instructions:

Useful for spotting omissions, duplicates, and confusing transitions from hospital to home.

If you request records, asking for them in a single packet helps. Medication issues are usually a timeline problem, so you want the documents that let you follow the sequence without gaps.

Questions Patients Often Have After a Medication Error

After a medication-related issue, uncertainty is often the hardest part. These questions reflect how patients and families typically try to make sense of what happened, especially when answers were not clear at the time.

Was this reaction expected, or was something unusual happening?

Many medications carry known side effects, but some reactions fall outside what would normally be anticipated. This question helps separate expected risk from outcomes that warrant closer review.

Did the medication plan take my full medical history into account?

Medications are chosen and dosed based on factors like existing conditions, allergies, and other drugs already in use. When one of these factors is missed or underestimated, safety can be affected.

Were there early signs that something was wrong?

Changes in alertness, breathing, vital signs, or lab results may signal that a medication is not being tolerated. Patients often wonder whether those changes were visible before more serious harm occurred.

Did the medication plan change as my condition changed?

Treatment decisions are not meant to be static. As a patient’s condition evolves, medications may need to be reassessed to remain appropriate.

What information would a reviewer need to explain whether this was expected risk or a breakdown in the process?

This question usually leads to a review of records, timing, and clinical decisions to understand whether the outcome was unavoidable or whether a different approach could have reduced risk.

We’ll listen, give you honest answers, and guide you every step of the way

so you can focus on healing, not fighting.

What to Do If You Suspect a Medication Error

When something feels off after a medication is given, most people are unsure how to respond. A good next step is to collect the documents that show what was ordered, what was given, and what changed in the patient afterward.

One helpful step is to request a complete copy of the medical records related to the treatment. This typically includes medication orders, administration records, pharmacy logs, and nursing notes. Having these documents allows you to see what was prescribed, what was administered, and how your condition was monitored over time.

It can also help to ask for a medication reconciliation. This is a review that lists all medications you were taking before, during, and after treatment. Comparing that list against symptoms or changes in condition often provides useful context.

Keeping a simple timeline can add clarity as well. Noting when symptoms appeared, when medications were started or adjusted, and when changes were observed can help connect events without relying on memory alone.

If questions remain after reviewing the records, some patients seek an independent medical explanation to better understand whether the outcome fits known risks or suggests something went wrong in the medication process. The purpose of this step is understanding, not assumption.

Approaching the situation methodically helps reduce confusion and ensures that any review is grounded in facts rather than speculation.

How Medication Error Cases Are Reviewed at Buchanan Firm

When patients or families reach out to Buchanan Firm about a possible medication error, the starting point is understanding, not assumptions. These situations are reviewed by reconstructing the sequence of care to see how medication decisions unfolded over time.

The review begins with medical records. Orders, administration logs, pharmacy documentation, and monitoring notes are examined together so the timeline makes sense as a whole rather than as isolated entries. The focus is on how information moved through the system and whether medication decisions aligned with the patient’s condition at each stage.

Because medication-related harm can be clinically complex, we have fast access to trusted, independent medical experts who help interpret whether the timeline reflects an expected risk or a breakdown in dosing, monitoring, coordination, or adjustment.

In many situations, the review confirms that the outcome was an adverse reaction rather than an error. In others, it identifies gaps in dosing, monitoring, coordination, or adjustment that raise questions about preventability. Either result provides clarity, which is often what families are seeking most.

This approach allows people to move forward with accurate information rather than uncertainty, regardless of where the review leads.

Frequently Asked Questions About Medication Errors

What qualifies as a medication error?

A medication error occurs when a drug is prescribed, dispensed, administered, or monitored in a way that does not align with the patient’s needs or the intended treatment plan. This can involve the wrong medication, dose, timing, or failure to account for relevant medical factors.

Are side effects always caused by a medication error?

No. Many medications have known side effects that can occur even when they are used correctly. A review looks at whether the reaction fits expected risk or whether something about the medication decision or follow-up deviated from standard practice.

Can a medication error happen even if the prescription itself was correct?

Yes. Harm can occur after prescribing, such as during dispensing, administration, or monitoring. In some cases, the medication choice is appropriate, but problems arise in how it is delivered or adjusted over time.

How do medical professionals determine whether a medication-related injury was preventable?

Preventability is evaluated by reviewing records, timing, patient condition, and clinical decisions together. The goal is to understand whether the outcome was unavoidable or whether different steps could reasonably have reduced risk.

What records matter most when reviewing a possible medication error?

Medication orders, administration records, pharmacy logs, nursing notes, lab results, and vital sign data are commonly reviewed. Together, these records help show how medication decisions were made and how the patient responded.

Do medication errors only happen in hospitals?

No. Medication errors can occur in many settings, including pharmacies, nursing homes, rehabilitation facilities, outpatient clinics, and during transitions between care environments.

Can more than one medication contribute to harm?

Yes. Some reactions occur because of interactions between drugs rather than from a single medication alone. Reviews often look at the full medication list to understand combined effects.

Why aren’t medication errors always caught right away?

Some effects develop gradually, especially when medication builds up in the body or interferes with organ function over time. In those cases, early symptoms may be subtle before becoming more noticeable.

Is a medication error always the result of one person’s mistake?

Not necessarily. Medication management often involves multiple steps and providers. Errors are frequently tied to communication gaps, coordination issues, or incomplete follow-through rather than a single isolated action.

What is the difference between a medication error and an adverse drug event (ADE)?

A medication error is a mistake in prescribing, dispensing, administering, or monitoring a medication. An adverse drug event is harm that occurs from medication exposure. Some ADEs are caused by errors, and some occur even when the medication was used correctly.

What does “medication reconciliation” mean, and why does it matter?

Medication reconciliation is a process used to compare what a patient was taking before treatment with what is ordered during treatment and what they are told to take afterward. It helps identify omissions, duplications, and interaction risks, especially during admission and discharge transitions.

Can a medication error happen during discharge or when switching care settings?

Yes. Medication lists often change during hospitalization, and confusion can happen when instructions are updated quickly, prescriptions are rewritten, or a patient moves from hospital to rehabilitation, nursing care, or home.

What is a Medication Administration Record (MAR), and can I request it?

A MAR (or eMAR) is the time-stamped record showing what medication was given, when it was given, and how it was administered. Patients and families often request it because it helps connect symptoms to specific doses.

Are certain medications considered higher risk for serious harm?

Some medications require tighter dosing and closer monitoring because small changes can have bigger effects. The risk depends on the specific drug, the patient’s age and health, and whether organ function or other medications change the way the drug is processed.

Why do medication problems sometimes show up hours or days later?

Some drugs build up over time, and some complications develop gradually, especially when medication affects breathing, blood pressure, kidney function, or electrolyte balance. In those cases, early warning signs can be subtle before they become obvious.

Tell Us Your Story

If you have questions about a medication-related outcome, it can help to walk through the timeline with someone who is used to reading medical records. Many people reach out because they want an explanation that makes sense, not because they already know an error occurred.

When you contact Buchanan Firm, we start by listening and gathering the details you remember, including what medication was involved, when symptoms started, and what you were told during care. From there, the next step is usually records, so the situation can be reviewed in sequence rather than from memory alone.

Sometimes that review shows an adverse drug reaction that could not have been avoided. Other times it shows gaps in dosing, monitoring, coordination, or adjustment that deserve a closer look. Either way, the goal is the same: clarity about what happened and what it means.