Managing medicines safely is one of the most challenging aspects of social care provision. There is just so much that can go wrong. Care staff take on a big responsibility when they support people to take their medicines and they need a high level of support themselves to ensure that they are working as safely as possible and that medicines errors are kept to a minimum.

A medicines error is “an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Mistakes in the prescribing, dispensing, storing, preparation and administration of a medicine are the most common preventable cause of undesired adverse events in medicine practice and present a major public health burden.” 

According to a study (Elliott, et al, 2019) published in the BMJ Quality and Safety Journal, an estimated 237 million medicine errors occur at some point in the medicines process in England annually. This figure is not exceptional compared to other countries. Estimated error rates are similar to those reported for the USA and countries in the European Union.  Although most errors do not lead to serious consequences, many people are hospitalised because of errors and they cause an estimated 1,700+ deaths every year in England.

Based on evidence reviewed for the study, the researchers said that “The medicines most often implicated in hospital admissions attributable to medicines errors are non-steroidal anti-inflammatories (NSAIDs); clot busters (anti-platelet drugs); drugs to treat epilepsy and low blood glucose; water tablets (diuretics); inhaled corticosteroids; and certain types of heart drugs (cardiac glycosides and beta blockers), say the researchers.

Most (80%) of the resulting deaths are caused by gastrointestinal bleeds from NSAIDs, aspirin, or the blood thinner warfarin.”

Medicines errors in care services

It is estimated that 21% of errors are made during prescribing and 16% during dispensing. However, by far the biggest percentage – 54% – are made at the point of administration. Regarding settings, around 20% of errors are made in hospitals, 38% in primary care and 42% in care homes, even though there are fewer people in care homes than there are in the other settings. No information was provided about the number of errors made where people receive care in their own homes. The most common type of medicine administration errors in care homes are: giving the wrong dose, giving the wrong medicine or giving a medicine at the wrong time. These are likely to be the same when medicines are administered by home care workers.

People who need care are particularly vulnerable to medicines errors. They are more likely than other people to have multiple health conditions and may well need to take several medicines. Keeping track of all of them may be difficult and there will be an increased chance of an adverse interaction between medicines. People who need care are also more likely to have impaired cognitive function and will be less able, or unable, to recognise that they are experiencing symptoms that indicate a medicines error.

Age- or illness-related decline in bodily functions can change the way medicines react with the body. Deteriorating renal function, for example, can cause some medicines to become toxic to the body. Some may be tolerated at a lower dose (e.g., statins) while others (e.g., NSAIDS) should not be taken at all.

All care services that administer medicines as part of regulated activity will be asked how they ensure the proper and safe use of medicines? (NICE, 2022) when they have CQC inspections.

NICE has developed two guidelines that set out good practice in medicines management and support social care providers to demonstrate that they meet the required CQC standard. These are Managing medicines for adults receiving social care (NICE, 2017) in the community and Managing medicines in care homes (NICE, 2014). Both guidelines state that care providers should have a medicines policy based on current legislation and best available evidence, and suggest processes that should be included in the policy. A medicines policy is fundamental to getting medicines management right.

MAR charts

Both of the NICE Managing Medicines guidelines emphasise the importance of accurate record-keeping, which has been identified as one of the biggest challenges in managing medicines. 

According to a Care Quality Commission report – Medicines in health and adult social care Learning from risks and sharing good practice for better outcomes (CQC, 2019):

“The key contributing factor for administration errors was poor record keeping. We saw that MARs (medicines administration records) were either not completed, or not completed accurately. Discontinued medicines and incorrect strengths of medicines were sometimes found on MAR charts. These types of errors were more likely when MAR charts were hand-written or included additional hand-written medicines. Where MARs were hand-written in care homes, they had not always been second checked to ensure they were accurate. Incomplete records of administration also applied to topical preparations and transdermal patches. Sometimes there weren’t any corresponding records to indicate where or when the preparations were to be applied.”

MAR charts have detailed information about a person’s medicines, including which medicines should be given; required dose; route of administration; when it should be taken and for how long. Social care providers are required by law to securely maintain accurate and up-to-date records about medicines for each person receiving medicines support. To meet this obligation, care workers have to update MAR charts every time they support someone to take medicine, whether they administer it or the person self-administers it. Records may be printed or electronic (eMAR).

Robust processes to ensure that medicines administration records are always accurate and up to date mean that everyone involved with a person’s care knows which medicines have been taken and when. This is vital for the safety of the person.  And, in the event of an incident where medicine administration is called into question, MAR charts may be required as evidence in clinical investigations or court cases. 

Information about managing an individual’s medicines support should also be recorded in their care plan. The focus here will be on the person’s needs and preferences about support, including who is responsible for providing support (particularly important when more than one care provider is involved); how they should be supported for each medicine they take and who to contact about their medicines. Clear and accurate information on the care plan will reduce the risk of errors.

Transition from one setting to another

Medicines errors are particularly likely to occur when people are transitioning from one setting to another, such as from a hospital to a care home or to their own home.

Every time a person transfers from one setting to another there is a risk that either their medicines or information about their medicines doesn’t go with them. This leads to missed doses, wrong doses, duplicated doses, administration of the wrong medicine and, ultimately, increased risk of harm to the person. Lack of communication between settings (or with family members and carers) means that errors are often not picked up promptly.

The NICE guideline on medicines optimisation (NICE, 20215) sets out recommendations for putting robust and transparent processes into place in care settings to ensure the prompt and safe transfer of information from one setting to another

Self-administration

Self-administration of medicines can lead to medicines errors if people are not supported properly. People should be able to choose to look after and take their own medicines unless a risk assessment suggests otherwise. Risk assessments should be repeated regularly to ensure that it is still safe for them to continue with self-administration. Sometimes care workers will not be responsible for giving people their medicines, but will be responsible for supporting them to self-administer their medicines, for example by removing packaging or reminding them when it’s time to take a dose. Any support that people need to self-administer medicines should be clearly detailed in the person’s care plan. Where people are living at home and family members are involved in their care it should be clear who is responsible for supporting self-administration.

Training

Lack of staff training can also contribute to medicines errors. NICE states that “Appropriate training, support and competency assessment for managing medicines is essential to ensure the safety, quality and consistency of care.” and both guidelines recommend that “Providers should ensure that all care staff have an annual review of their knowledge, skills and competencies relating to managing and administering medicines.”

Human error causes medicine error. Even with good training, care staff may still make mistakes. They are more likely to occur when staff are tired or have too much work to do in the time allotted. Unfortunately, lack of time is a common problem at the moment because of the difficulties in recruiting and retaining social care staff. Time pressures can also lead to incidents that are beyond the care worker’s control, for example where the worker is not able to get to a person in time to administer a medicine dose that is time-sensitive. When it is impossible to staff a service adequately, staff need to be aware that safe administration of medicines is a priority.

Reporting errors

It is inevitable that, even when providers have good processes for medicines management in place, errors will still occur. People receiving care, their families and friends and staff must be aware of how to identify and report errors and they should be actively encouraged to report any concerns. Staff should report errors without delay. They will be more willing to do this where there is a ‘fair blame’ culture. This means enabling open and honest reporting of mistakes by treating them as an opportunity to learn how they can be avoided in the future. Full details about an incident should be recorded as soon as possible after it occurs and there should be a clear process for sharing learning from incidents across the organisation

The safety of the person should be the primary concern when an incident occurs. If there is any risk of harm to a patient, care workers should know who to contact in normal office hours and out of hours and what do in the case of an emergency.  

There is no requirement to notify CQC about all medicines errors, but they must be informed if an error has caused:

  • a death
  • an injury
  • abuse or an allegation of abuse
  • an incident reported to or investigated by the police.

Serious medicines errors may also be classified as safeguarding incidents. Thresholds for identifying safeguarding incidents vary from local authority to local authority, so providers need to be aware of local arrangements for notifying suspected or confirmed medicines-related safeguarding incidents. Recognising that there is a lack of consistency across the country about defining safeguarding incidents, NICE suggests that the following criteria could be used to identify them:

“A safeguarding issue in relation to managing medicines could include the deliberate withholding of a medicine(s) without a valid reason, the incorrect use of a medicine(s) for reasons other than the benefit of a resident, deliberate attempt to harm through use of a medicine(s), or accidental harm caused by incorrect administration of a medicine error.” (Managing medicines in care homes)

Providers should also be aware that incidents involving controlled drugs should be reported to the local Controlled Drug Accountable Officer.

Ensuring good medicines support

Care workers need to know how to act in any situation relating to medicines administration, so it is essential that there are robust processes in place to support them. NICE recommends that processes focus on ensuring that the ‘6 R’s (rights) of administration have been met before a medicine is administered. These are:

  • right person
  • right medicine
  • right route
  • right dose
  • right time
  • person’s right to decline

Both guidelines have detailed recommendations about the information that should be included in these processes.

About the author

Kim Rutter is a writer and policy expert who worked at the Social Care Institute for Excellence (SCIE) for 16 years before joining the National Institute for Health and Care Excellence (NICE) Collaborating Centre for Social Care.