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Health, Support & Social Care

Medication errors in care homes

To meet CQC standards, care homes must follow NICE guidance SC1, which emphasises the importance of having a robust process for identifying, reporting, reviewing, and learning from medication errors involving residents.

Medication errors often arise from weak systems or human factors. For example, poorly designed medication charts can complicate order processing and record keeping. A lack of coordination between staff and healthcare providers may lead to inconsistent practices, but also relying on outdated communication methods like telephone and fax can hinder the timely and accurate exchange of critical information.

By addressing these challenges and aligning with NICE recommendations, care homes can significantly improve medication safety and ensure compliance with regulatory standards.

Residential Care Social Care Compliance
3 minutes
HSC Roxana Florea writer on Health and Social Care

by Roxana Florea

Writer on Health and Social Care

Posted 18/09/2025

medication scattered on a blue surface

Why Medication Errors Happen in Care Homes

1.Poor communication with doctors 

Sometimes medication errors stem from poor communication among the nursing staff and the doctors. This can involve messy handwriting, ambiguous abbreviations, and confusion between drugs with same-sounding names.

2. Dosage error

This usually happens when either a doctor prescribes a new medicine or asks to stop the old one. For instance, a doctor may have suggested stopping a particular medicine for a particular problem. However, the resident may require that dosage for another ailment. This confusion can result in either overdose or underdose.

3. Right medicine but wrong route

There are many ways of administering different medicines. Some pills are taken orally, others through inhalation (such as breathing medication as a mist from an inhaler), transdermally, rectally, or as an injection. It is better that the doctor and the nursing staff are clear on the route for administering medication.

4. Wrong patient

Same-sounding names and change in rooms and bed numbers are one of the few reasons that can result in administering medications intended for one patient to another patient.  The best way to avoid this is to have more than one way of verifying a patient. Some care homes go by a patient’s room number while some check ID number.

Having more than one layer of checking can help avoid this problem and initiate more effective medication management solutions within your care home.  This is one of the common mistakes that happen when the nursing staff is still using paper medication administration. But these changes should be legible and comprehensive, because rewriting and overwriting can cause confusion.

5.Lack of knowledge about drug interaction

Different drugs interact with each other differently. This is why some medicines are not prescribed along with others. However, a lack of knowledge about drug-drug interaction can have a serious consequence.

Whenever a new medicine is prescribed, the nursing staff must either check or bring to the doctor’s notice the existing medicines that the resident is taking. An overall review of medication can help avoid this problem.

hand holding a several pills

The Role of eMAR and Digital Tools in Reducing Medication Mistakes

As a software provider you might expect us to offer a technological solution to everything! There are steps providers can take to reduce errors without software for details on a review of digital tools and apps provided by the NHS visit this literature review by the NHS.

But when it comes to medicine errors in care homes, technology is increasingly being recognised as the essential ingredient in running a safe establishment.

According to the CQC “Electronic medication management (eMar) systems can:

• Help staff to record the medicines given to people in their care.
• Minimise mistakes or incomplete records.

Staff can access digital care plans and records more easily. They can record information in real time. This can be quickly and accurately shared to help keep people safe, and highlight key information, such as up to date medical and allergy information.”

Access Medication Management is a more comprehensive version of eMAR. Designed specifically for care homes and nursing homes it helps you manage everything medicine related, from stock control to administration, with tons of safety features to reduce - and in most cases eradicate - serious medicine errors such as missed medicines.

Recently, the NHS partnered with Digital Social Care and highlighted how Access’ integrated electronic care planning and medication management system:

  • Reduces medication errors and near misses.
  • Improves management of medication stocks.
  • Supports efficient analysis of data to identify trends at individual resident, care home and group level.
  • Frees up nurses time, as more staff are involved in recording information.
  • Enables care staff to maintain and access up to date information.

Those providers featured by the NHS and Digital Social Care are not solitary pioneers anymore. Residential care providers of all shapes and sizes, across the UK are realising that electronic medication management software is the most robust and reliable system you can have, and the greatest asset in reducing serious medicine errors.

Our Erskine Care case study, highlighting the experience of nurses, care workers and managers with Access Medication Management.

Reduce Medication Errors in your Care Home

Medication errors in care homes can have serious consequences, but they are preventable. From improving communication and staff training to embracing digital solutions like Access Medication Management, care providers have powerful tools at their disposal. By taking proactive steps and leveraging technology, care homes can create safer environments for residents and empower staff to deliver the highest standard of care.

Discover how Access Medication Management can transform safety, streamline workflows, and empower your staff.

HSC Roxana Florea writer on Health and Social Care

By Roxana Florea

Writer on Health and Social Care

Roxana Florea is a Care writer within the Access Health, Support and Care team.
 
Holding a Bachelor of Arts in Creative Writing, she is passionate about creating informative and up-to-date content that best supports the needs and interests of the Care sector.
 
She draws on her solid background in editing and writing, breaking down complex topics into clear approachable content rooted in meticulous research.