The five medication errors we see most, and how to stop them

In the landmark Care Homes' Use of Medicines Study, researchers followed 256 residents across 55 UK care homes. Residents were taking an average of eight medicines each. 69.5% of them experienced at least one medication error, with an average of 1.9 errors per resident, and errors happened at every stage: prescribing, dispensing, monitoring and administration.

The causes it identified are still familiar on medication rounds today: heavy workloads, interruptions, gaps in training and inaccurate records. Across the whole health system the scale is large too:

Those national harm estimates include no care home data, so the true picture in social care is unknown. Here are the five errors I see most often in my training work, and how to prevent each one.

1. Omitted doses

A tablet missed because the person was asleep, out or refused, and nothing was recorded or followed up. Omissions are easy to dismiss as minor, but missing an anticoagulant, an anti-epileptic or a Parkinson's medicine can cause serious harm.

Prevent it: record every refusal or omission with a code and a reason. Know which medicines are time-critical, and escalate a missed dose to the pharmacist or GP the same day.

2. Wrong time

Some medicines must be given at precise times. Parkinson's medicines are the classic example: a delay of even 30 minutes can affect a person's movement and swallowing. Others must be taken before food, or apart from other medicines.

Prevent it: flag time-sensitive medicines on the MAR chart and in the care plan, and don't let a long round push them back.

3. Interrupted rounds

The CHUMS researchers identified interruptions during drug rounds as a key cause of error. Every interruption breaks concentration at the moment it matters most.

Prevent it: use a "do not disturb" tabard or sign during rounds, and agree as a team that the person giving medicines is only interrupted in an emergency.

4. Recording errors

A missing signature, a signature for a medicine not given, or a handwritten MAR entry no one can read. If it is not recorded accurately, the next person cannot give care safely, and you cannot evidence that it was given.

Prevent it: sign immediately after the person has taken the medicine, never before. Have handwritten MAR entries checked and signed by a second trained person.

5. "As required" (PRN) medicines without guidance

Pain relief or anxiety medicines given "when needed" with no clear protocol. Too often the decision is left to whoever is on shift.

Prevent it: every PRN medicine needs a protocol covering what it is for, the signs that it is needed, the dose, the minimum gap between doses and the maximum in 24 hours. Record why it was given and whether it worked.

A word on covert medicines

Hiding medicine in food or drink is sometimes necessary, but only when a person lacks capacity to make the decision, a best interests decision has been made under the Mental Capacity Act, and a pharmacist has advised how to give it safely. It should never be a shortcut for someone who is simply refusing.

Training and competence

NICE guidance on managing medicines in care homes says only staff who have been trained and assessed as competent should give medicines, with their competence reviewed every year. The CHUMS study found a lack of medicines training was one of the root causes of error. Good training is not a box-tick; it is the main defence.