Patient Safety Collaborative

Safer administration in care homes is part of the National Medicines Safety Improvement plan which has an overall aim of reducing severe avoidable medication related harm by 50% by 2024.  

Why are we doing this work? 

A UK review to understand the prevalence and economic burden of medication errors in England, showed that of the estimated 237 million medication errors per year in England, 92 million occur in care homes. Two studies were identified that looked at medication administration errors in care homes.  

• One study reported a medication administration error rate of 30.8% for those without dysphagia and 57.3% for those with dysphagia.
• In the study measuring medication errors in care homes, prescribing errors were 39.1%, monitoring 18.4%, dispensing 36.7% and administration 22.3%. 

Often residents in care homes rely heavily on their carers or nurses to access the medicines they need. 

The PSC undertook a diagnostic phase during 2019/20 to identify promising interventions that reduce medication administration errors. While no single intervention was identified as having a direct impact on the safer administration of medicines in care homes, it suggested four change ideas that require further testing that are termed “secondary drivers” in the Medicines Safety Improvement Programme (MedSIP) current workplan.