Medication errors in care homes 

This work led to many important initiatives including a study of care home use of medication that showed 70% of care home residents had at least one medication error at any given time.

Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. 

A prospective study of a random sample of residents within a purposive sample of homes in three areas.  Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. 

The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews 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 medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. 

Our conclusion was two thirds of residents were exposed to one or more medication errors. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned. This research led to a National Patient Safety Agency alert..

Barber N, Raynor D Buckle P et al  (2009) The Care Homes Use of Medicines Study: prevalence, causes and potential harm of medication errors in care homes for older people.  Quality and Safety in Health Care 18: 341-346 

 Lim R, Anderson J, Buckle P (2008) Analysing care home medication  errors using work domain analysis In: Improving Patient Safety 2008 ‘From Safe Design to Safe Practice’. Eds Hignett S, Norris B, Catchpole K, Hutchinson A and Tapley S. Publ Ergonomics Society, England ISBN 978-0-9554225-2-2    pp 147-151