This paper explores the root cause of a medication error that occurs in an assisted living facility. Due to many causing factors, a care manager (CM) gives a resident the wrong set of pills. Making medication errors can lead to very serious adverse events that can lead to dangerous outcomes. Medication administration takes knowledge and skill. It’s important to follow the five rights of medication administration and to understand medication safety. When steps and checks to administering medications are missed the chances of an error occurring are increased. Interventions that can help prevent this from occurring are the following: admitting a mistake has occurred and learning from that mistake, communicating with staff, acquiring new technology,
