ADVERTORIAL

Medication errors remain a persistent and costly challenge in post-acute and long term care (LTC). Estimates suggest that between 16 percent and 27 percent of residents experience a medication error, with as many as one in ten resulting in serious medical complications. Each year, adverse medication events contribute to approximately 800,000 preventable medication-related injuries and more than $4 billion in excess health care costs.

The encouraging news is that nearly 40 percent of these adverse events are considered preventable. That raises two important questions for operators: Where are these risks happening? And are they being caught before they reach the resident?

Insights into these risks are increasingly informed by real-world clinical intervention data—captured as senior care pharmacists review, clarify, and adjust medication orders in the course of daily care delivery in LTC and senior living.

For many organizations, medication-related harm is still viewed through the lens of downstream events: a missed dose, a survey finding, or a hospitalization. But what this data shows is that most medication-related risk begins much earlier in the process, often during ordering, transitions of care, or routine therapy adjustments.

Where Medication Risk Actually Occurs

In 2025, Guardian pharmacists documented more than 102,000 clinical interventions, impacting nearly 76,000 residents across LTC, senior living, and other care settings.

Each intervention represents a potential medication-related issue identified and addressed before it reached the resident, providing a clear view of where risk is most likely to occur in everyday practice.

That visibility reveals seven key trends:

1. Ambiguous orders remain one of the most frequent risks. More than 25,000 pharmacist-led interventions involved order clarifications such as resolving incomplete, conflicting, or unclear orders before dispensing.
2. Drug-drug and drug-disease interactions require ongoing oversight. Nearly 9,200 interventions identified therapies that increased the risk of adverse effects, toxicity, or the need for additional monitoring.
3. Dosing issues continue to put older adults at risk. Approximately 9,100 interventions addressed doses that were too high, too low, or otherwise inappropriate based on the resident’s age, condition, or clinical profile, underscoring the importance of experienced senior care pharmacist oversight.
4. Polypharmacy continues to be widespread in practice. Approximately 9,000 duplicate therapies were identified, highlighting the ongoing need for proactive medication reviews to reduce the downstream effects of overprescribing, especially for residents with complex medication regimens.
5. Allergy-related risks still surface despite documentation. In over 7,300 instances, pharmacists intervened when medications were prescribed that conflicted with a resident’s documented allergies, requiring clarification, therapeutic substitution, or additional monitoring.
6. Omissions in therapy continue to occur in practice. In more than 3,000 instances, pharmacists identified medications that were indicated but not prescribed, requiring follow-up to ensure appropriate therapy.
7. Deprescribing remains an important part of medication management. Nearly 2,600 interventions involved potentially inappropriate or no longer beneficial medications that warranted discontinuation.

Where Transitions of Care Create Additional Risk

One of the most consistent themes in clinical intervention data is the impact of care transitions. With frequent admissions and transitions, more than 62,000 medication reconciliations—comparing lists from various sources to determine the most accurate medication list—were required.

Admissions, hospital discharges, and internal level-of-care changes introduce new medication lists, new prescribers, and often incomplete or conflicting information. These transitions require rapid reconciliation and decision-making, frequently under time pressure.

Medication reconciliation is not a one-time task, but an ongoing process. Each transition creates an opportunity for discrepancies, omissions, or duplications that can affect resident safety and outcomes.

For post-acute care operators in particular, where shorter lengths of stay and higher acuity are the norm, these risks are amplified. Delays or inaccuracies during transitions can directly contribute to therapy interruptions, survey deficiencies, and hospital readmissions.

The Role of Clinical Oversight in Preventing Harm

The consistent theme across Guardian’s clinical intervention data is that medication risk is manageable, but only when it is actively monitored.

Clinical intervention represents the work that happens before a medication reaches the resident. It includes reviewing orders in the context of the resident’s full profile, identifying inconsistencies or risks, and collaborating with prescribers and care teams to resolve issues in real time.

In practice, this includes:

• Identifying potentially inappropriate or duplicate therapies before dispensing.
• Adjusting doses based on resident-specific factors, such as age or medical condition.
• Clarifying incomplete or conflicting orders.
• Reconciling medication lists during care transitions.

In 2025, these activities accounted for more than 35,000 pharmacist hours dedicated to clinical oversight and collaboration across Guardian’s network of more than 50 LTC pharmacies.

From Individual Actions to System-Level Insight

Beyond resolving individual issues, clinical intervention data provides operators with visibility into broader patterns of risk.

Tracking and categorizing interventions allows organizations to:

• Identify where medication risks are most likely to occur.
• Understand trends tied to transitions of care or high-risk therapies.
• Demonstrate proactive oversight during surveys and audits.
• Support continuous improvement in medication management practices.

This shifts medication safety from a reactive process to a measurable component of quality and risk management.

What This Means for Operators

Medication-related risk in LTC and senior living is not new, but the ability to measure and manage it at scale is.

For operators, the implication is clear: preventing harm requires more than policies and procedures. It requires consistent, real-time clinical oversight and visibility into where risks are occurring within their communities.

As staffing challenges, resident acuity, and regulatory expectations continue to increase, this level of insight becomes even more important. Reducing medication-related risk is not only a clinical priority. It directly impacts operational performance, staff workload, survey readiness, and resident outcomes.

Most medication-related harm is preventable, but only if it is identified and addressed before it impacts the resident.

To learn more about Guardian’s Clinical Intervention program and the GuardianShield suite of services, visit guardianpharmacy.com/guardianshield.