NPC Archive Item: Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

NOTE – This is an archive post from the NPC and has not been updated since first publication. Therefore, some hyperlinks may no longer be working.

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20th October 2009

In October 2009 the results from the Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people1 were published.  The objective of the study was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. The results of the study have generated much interest as the authors call for action from all concerned to address the need for improvement.

The results found that 69.5% of residents involved in the study had experienced one or more medication errors.  Contributing factors to the findings included:

  • Doctors who were not accessible, did not know the residents and lacked information in homes when prescribing
  • Home staff’s high workload, lack of medicines training and drug round interruptions
  • Lack of team work among home, practice and pharmacy
  • Inefficient ordering systems
  • Inaccurate medicines records and prevalence of verbal communication
  • Difficult to fill medication administration systems

In it’s discussion section, the authors of Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people1 make several suggestions that could contribute to improved patient safety in care homes.

These include:

  • Exploring the suggestion of a lead GP for each home; ensuring appropriate monitoring of patients on riskier medicines and that all patient’s medication is reviewed by a pharmacist
  • Consideration of one person, perhaps a pharmacist, having overall responsibility for medicines use in one or more care homes
  • Constant review of the use and accuracy of medication administration records. (The authors noted that lack of protocols and adequate staff training is an issue)
  • Prescribing medicines for different times to ease busy morning drug rounds which can often be interrupted
  • Monitoring of omitted doses and ordering systems , particularly of “as required” medicines, to reduce administration errors from omissions when a drug is not available

Everyone involved in medicines management systems and processes in care homes, including care home managers, healthcare professionals and staff, and commissioners who have a lead role in ensuring safe medication practices are embedded in patient care, should read this document and take action.

Medication errors can occur at any stage of the medicines management process, from prescribing and dispensing through to administration and monitoring.2

As reported in Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people1, prescribing has been found to be suboptimal in UK care homes, although the prevalence of medication errors in this setting in the UK is not known.

The Department of Health released the report Building a safer NHS for patients: Implementing an organisation with a memory in 2001, 3 which set out the Government’s commitment to reducing medication errors, as well as the agenda for improving care by reporting and learning from adverse events. This was followed by a further report Building a safer NHS for patients: Improving Medication Safety in 2004.4 As well as other recommendations, the 2004 report highlighted that errors in prescribing may occur in the care home environment due to prescribing decisions being inadequately recorded, and that decisions made by GPs during care home visits must be incorporated into the patient’s records in a timely manner. The report also stressed that the application of procedures, checks and defences is especially important in care home settings if safer administration of medicines is to be achieved.

What does this mean to medicines management?
Older patients in care homes (residential, nursing or combination) are a frail and vulnerable population at particular risk of medication errors. Medicines Management in care homes needs to focus on improving the systems designed to support prescribing, dispensing, administration and monitoring. This can be achieved by reducing the likelihood of human error through effective training that takes into account the knowledge of how medicines are used, how to recognise and deal with problems as they occur, and encourage staff to report and learn from medication errors (through the National Reporting and Learning System (NRLS)) that have occurred previously.

How does this relate to other publications or evidence?
The article National Minimum Standards in care homes: what roles do pharmacists have?, published in the Pharmaceutical Journal in 2002, identified the important role suitably qualified pharmacists could have in supporting care homes to improve medicines management by, amongst other things, acting as an important source of medicines information to carers; providing assistance with medicines controls by keeping patient medication records; and providing computer generated Medicines Administration Record (MAR) charts and monitored dosage systems.

The NPC currently has a number of medicines management resources that support improved practice in all care settings.  Some of these resources are particularly relevant to medicines management in care homes and should be signposted to by organisations wishing to respond to the call for action.

These resources include the following NPC sections:

  • Medicines Management in Care Homes (Focus includes: Understanding current regulations and standards for medicines use in care homes; the principles of good practice in handling of medicines in care homes; and the benefits of robust policies and procedures for medicines handling in care home)
  • Reducing Medication Errors (Focussing on enabling people to: use tools for assessing and reducing medication errors; identify steps in the medication process where errors can and do occur; understand and contribute actively to the reporting of medication errors; develop practice to improve the detection and management of medication errors; and contribute to reducing medication errors through a range of actions and interventions
  • An Introduction to Medicines Management (Focus includes: Understanding what ‘medicines management’ is, and how it is used in different situations; the benefits of good medicines management ;  barriers and potential solutions  to improving medicines management)
  • Medicines Management in Long Term Conditions (Focus includes: understanding the problems commonly faced by people who have to take medicines as part of the management of their condition; problems facing people with specific common long term conditions; and potential solutions to medicines-related problems)

And the documents:

Readers wishing to share initiatives which have improved medicines management in care homes can complete and submit an NPC Medicines Management example of improvement form.  All examples of improvement would appear in the Medicines Management examples of improvement section of the NPC website.  

1. Barber, ND, Alldred, DP, Raynor, DK, Dickinson, R, Garfield, S, Jesson, B, Lim R, Savage I, Standage, C, Buckle, P, Carpenter, J, Franklin B, Woloshynowych, M, Zermansky, AG, (2009). Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

2. Department of Health (2008) The Pharmacy White Paper: Building on strengths and delivering the future.

3. Department of Health (2001). Building a safer NHS for Patients: Implementing an organisation with a memory.

4. Department of Health (2004). Building a safer NHS for patients: Improving Medication Safety.

Please comment on this blog in the NPC discussion rooms, or using our feedback form.