Medication errors can occur within care homes, domiciliary care settings, supported living providers and schools as well as in our own family home. Most come from busy environments, unclear processes, and little mistakes that compound over time.
The aim isn’t perfection. The goal here is to mitigate the risk, diagnose problems early and establish habits that in turn provide assurance for your people. For Safe handling of medication, visit https://www.tidaltraining.co.uk/health-and-social-care-courses/safe-handling-of-medication-training
Common causes of medication errors
1) Distractions and interruptions
Phone calls, questions, doorbells – often an urgent necessity. This can cause you to take the wrong dosage or lose track.
2) Poor documentation
Well, if MAR charts aren’t filled out properly and immediately then some other person can easily think a dose was given (or not). Also, with no notes about refusals or PRN medication changes this can also be very confusing.
3) Similar names and packaging
Similar looking, similar sounding medications are known risks. The more the labels are like each other, as well as blister packs that look similar and patient names can increase picking errors.
4) Unclear instructions or changes
Changes in medications (new prescriptions, dose adjustments, discontinued meds) are also high risk moments and particularly when handovers have not had time to undertake a shared mental model/written updates.
5) Not training or not confident
Procedures, escalation, or what to do when something doesn’t look right for example; new staff/ agency staff /staff that don’t manage medication regularly may be very well trained in specific procedures but they won’t necessarily be confident when an escalating situation occurs.
Preventing Medication Errors (Real World Solutions)
Protect the process
Develop a policy in medication handover whenever feasible
Have everything you need before starting (MAR chart, keys and water/ppe)
Strengthen checks
Compliance with the 5 rights (right person, medication, dose, time and route)
Check with others before administering high risk meds and controlled drugs (protocol applies).
Improve documentation
Write up immediately after you have given them, NOT LATER
Record refusals, omissions and reasons PRNs were refused in detail.
Make handovers safer
Medication changes should always be highlighted in handover notes
Be sure that changes have been documented in the MAR chart and care plans.
Build a learning culture
Report near misses without fear of blame
Pattern of failure: From where and when does some processes break down?
If an error happens
Does this follow your organisation’s policy? Escalate quickly and clearly. Quick action can prevent harm.
Most of what constitutes good medication practice is simply calm routines, clear records and supervision, not charging through hoping for the best.
