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Secretary of State for Health and Social Care, Jeremy Hunt, recently highlighted research which indicates that GPs, pharmacists, hospitals and care homes could be making up to 237 million medication errors a year – which is the equivalent of one mistake made for every five medicines administered. Researchers from the Universities of York, Manchester and Sheffield have reported that an estimated 712 deaths as a direct result of medication errors but claim errors could have been a contributory factor to between 1,700 and 22,303 deaths a year. In fact, in 2017 the World Health Organisation (WHO) confirmed that unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually[i]. WHO declared that ‘Medication Without Harm’ as the theme for the third Global Patient Safety Challenge.

Medication errors can occur at different stages of the medication use cycle and occur when weak medication systems and/or human factors such as fatigue, poor environmental conditions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death. Numerous studies, projects and interventions to address the frequency and impact of medication errors have already been developed, yet the implementation of any recommendations and learning is often varied and tends to be primarily focused on healthcare settings rather than social care settings.

In the history of the NHS, there has never been such a focus on improving the quality of health services and yet this is not necessarily the case in social care. Social care providers, including care homes, are required to have independent policies and procedures for medicines management including the identification and reporting of medication errors and yet the quality and implementation of such policies if often poor or absent.


NICE guidance[ii] on medicines management in care homes clearly states that both ‘commissioners and providers of health or social care services should ensure that there are robust processes in place for identifying, reporting, reviewing and learning from medicines errors involving residents’. Implementation of this guidance recommendation varies nationally and this is evident form the Care Quality Commission (CQC) annual report ‘The state of adult social care services 2014 to 2017’ in which medicines management was a key factor associated with unsafe care. Specific issues included:

  • Medicines not being administered properly
  • Staff lacking knowledge of medicines and their side effects
  • Issues with record keeping, including timeliness
  • A lack of medicines audits
  • Medicines being out of date and not being stored correctly

The primary aims of this project would be for health and social care staff to work collaboratively with care home providers, care home residents (and/or their representatives) to:

  • create and implement a checklist/tool for care home staff to identify medicines safety risks/gaps and look at where medication safety improvements could be made
  • provide training and good practice guidance for care staff on how to reduce medication errors
  • introduce a number of interventions to improve reporting and reflection on medication errors and incidents
  • create a list of simple checks/changes to practice for doctors to optimise safer prescribing of medicines for care home residents


  • Reducing harm caused from medication errors or improper use of medicines
  • Reducing number of avoidable medicines related hospital admissions
  • Improving quality of life and well-being for care home residents
  • Empowering social care staff to improve quality of care through medicines safety
  • Collaborative working and sharing of quality improvement models/practices with social care
  • Improved collaborative working and understanding of medication risks and benefits
  • Avoiding waste and costs associated with avoidable medicines related hospital admissions
  • Promotes NHS values and objectives
  • Supports the WHO third Global Patient Safety Challenge ‘Medication Without Harm’


  • East Berkshire CCG
  • East Berkshire care homes
  • Oxford patient safety collaborative and Oxford AHSN network to provide guidance on governance and improvement methodology (TBC)
  • Frimley Health NHS Foundation Trust
  • Frimley Health and Care ICS Care homes quality governance group to support governance and implementation (TBC)
  • Healthwatch (East Berkshire) (TBC)
  • Berkshire Care Association (TBC)


[i] WHO Global Patient Safety Challenge: Medication Without Harm, 2017, []

[ii] Managing medicines in care homes, NICE [SC1], March 2014, []

How you can contribute

  • Are any of the Q community (who may be doing something similar) interested in collaboration?
  • It would be great to hear from colleagues in social care or those who have done similar pieces of work to help guide us from their previous learning?
  • Do you think we’ve missed something? Is there something that you think we should include to improve the proposal?Are any of the Q community (who may be doing something similar) interested in collaboration?
  • It would be great to hear from colleagues in social care or those who have done similar pieces of work to help guide us from their previous learning?
  • Do you think we’ve missed something? Is there something that you think we should include to improve the proposal?


  1. Hi Sundus, this is certainly an area ripe for improvement work and one that most health communities will recognise as a current problem. Happy to see if there is any collaboration that could occur with us down here in the far SW!

  2. Guest

    Debbie Brazil 2 years, 10 months ago

    Luton CCG have been doing a lot of work with care homes including systematic medication reviews, which both reduces wats but also means patients end up on a better balanced set of medications with fewer side effects. They may have considered some of the issues you are exploring. I can connect you with the lead pharmacist if that would help.

  3. Hi Sundus, will you be working with the CQC as many of the issues you highlight are also issues that CQC inspections pick - co-developing something will be really helpful for care homes.

    Also worth noting that the NHS England Medicines Optimisation in Care Homes Programme will be offering every STP funding to deploy pharmacists and pharmacy technicians into care homes - hopefully you will be linking into that locally,

    On both accounts, happy to help and connect you; please get in touch.

    Good luck.

    1. I should have said, hope you are going to support this project!  :)

    2. Hi Was,

      Thanks for your comment. We will invite our local adult social care CQC inspectors to become stakeholders to share their knowledge and experience around the actual issues and medicines safety concerns they pick up. However, they tend to stay clear of providing solutions as their role is a regulatory one and so I don't think they would 'co-develop' any tool or resource to improve quality/safety in medicines usage/administration.

      Frimley Health ICS have applied for the NHSE funding for care home pharmacist roles so I'm hoping we'll get funding soon and yes, any pharmacists involved in that will hopefully be part of this project.

  4. Hi Sundus, we have submitted a bid to develop our care homes community of practice in Nottinghamshire & Nottm city. This group aims to facilitate learning, sharing research evidence & supporting quality improvement. One recent activity has been development & implementation of a medications review. It would be great to share ideas, and to develop a care homes QI network!



    1. Hi Neil,

      A care homes QI network sounds like a great idea! I'll look to see how we can start one and be sure to get back to you.

  5. I think some process mapping would help in this project. If you need any help with that please contact me. A very worthwhile idea. Regards Tom

    1. Hi Tom,

      Many thanks for your comment and any support from yourself with process mapping would be most welcome. We have plenty of guidance and evidence around medicines management and medicines safety in care homes, we just need action on the ground now for the safety and quality benefits to be realised for patients. Please do support this idea and I will be in touch!

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