Medication errors are one of the most common types of adverse events in healthcare, and they are among the most clearly documented. That makes them both common in litigation and highly fact-specific. The question in most cases is not whether an error occurred, but whether it was caught in time, what was done about it, and how transparent the documentation was.
The Five Rights Still Matter
Every nursing student learns the five rights of medication administration: right patient, right drug, right dose, right route, right time. They exist because errors happen in each of those categories regularly. When I review a chart for a medication error claim, I am checking all five, not just the one the complaint mentions.
What the MAR Shows You
The medication administration record is the primary document. It shows what was ordered, what was given, when it was given, and who gave it. Gaps in the MAR, where a scheduled medication shows no administration and no notation of refusal or hold, are significant. So is the pattern over time. One missed dose may be explainable. Eight missed doses across three shifts is a different situation.
High-Alert Medications
Certain medications carry a higher risk when errors occur: anticoagulants, insulin, opioids, sedatives, and chemotherapy agents. Most hospitals have additional safeguards for these, including double-check requirements before administration. If a high-alert medication error is alleged, I look specifically for whether those safeguards were documented. If they were skipped or not documented, that is a relevant finding.
When Errors Are Not Documented as Errors
This is the part attorneys often miss. Medication errors are not always recorded as errors in the chart. A note that says "patient unresponsive, physician notified" may be the only documentation of a narcotic overdose. The error itself was never formally reported in the record. Knowing how to recognize the clinical signs of a medication adverse event, and then locating where in the chart that event surfaces even when it is not labeled, is what a legal nurse consultant brings to these cases.
If you have a case involving a medication adverse event and are not sure whether the records support it, that is exactly the kind of review that pays off early.