Top 5 medication errors in care settings and how to avoid them

Medication errors have long been a common problem within health and social care and has been recognised as a global issue in healthcare in the last few years. In England alone, BMJ reported recently that more than 237 million medication errors are made every year, which costs the NHS upwards of £98 million and more than 1,700 lives. 

According to the research, errors are made at every stage of the medication administration process, with 54% being made at the point of administration and around 1 in 5 made during the prescribing stage. Dispensing also accounts for 16% of total errors. 

This data looks at health and social care as a whole, including care homes, primary care and hospitals. From the data, it can be seen that care homes account for the highest error rates, sitting at just under half (42%).  

Given the vulnerability of care home residents, many of whom are older adults with multiple health conditions and complex medication regimes, ensuring safe medication practices is critical. In this blog, we’ll explore the five most common types of medication errors in care homes, along with practical steps on how to prevent them. 

Administering the wrong dose 

Administering the incorrect dose of medication is one of the most common and potentially dangerous errors in a care setting. This may happen due to misreading a prescription, confusion over decimal points, incorrect use of measuring devices, or failure to adjust doses following changes in a resident’s condition or weight. 

The consequences of such errors can be serious. An overdose can result in toxicity or organ damage, while an underdose may lead to ineffective treatment, particularly for conditions that rely on precise dosing, such as epilepsy, diabetes, or heart failure. 

To reduce the risk of such errors, staff must be trained in reading and interpreting medication instructions correctly. Electronic medication administration record systems, such as ATLAS eMAR, can add an extra layer of safety by alerting staff to possible dosage issues or changes. Clear communication with GPs and pharmacists is also vital, especially when new prescriptions are introduced or existing ones are amended. 

Where high-risk medications such as insulin or controlled drugs are involved, another trained staff member should always verify the dosage before administration. (Read more here for essential medication management training courses for care homes).  

Missed or delayed doses 

Missed or delayed medication doses are another frequent issue in care homes. These errors often occur during shift handovers, busy periods, or when staff are unavailable. Sometimes medication is delayed because the resident is asleep or away from the home. Although it might seem like a minor issue, some medications must be given at specific times to be effective or to avoid complications. 

For instance, Parkinson’s medications must be taken at strict intervals to control symptoms. A delayed dose can cause significant discomfort and reduce mobility. Likewise, missing antibiotics or anticoagulants can increase the risk of infection or blood clots. 

To prevent these errors, care homes should maintain clear medication timetables that are visible and accessible to staff. Digital systems can provide alerts when medication is due, helping staff keep on schedule. It’s also essential that medication rounds are treated as a priority during every shift. 

Giving medication to the wrong resident 

Administering medication to the wrong resident is a serious error that can have severe consequences. This mistake often occurs when two residents have similar names, or when staff are distracted or rushed. Even medications that seem harmless can cause adverse reactions when given to someone for whom they were not prescribed. 

To avoid such incidents, staff should always confirm a resident’s identity before giving any medication. This might involve asking the resident to confirm their name, checking a photo on the MAR chart, or verifying details using a wristband or care plan. Following the five rights of medication administration — the right person, right medication, right dose, right route, and right time — is essential in every case. 

Creating a calm, interruption-free environment for medication rounds also plays a major role in reducing these kinds of errors. 

Did you know? With ATLAS eMAR’s barcode scanning system, you can only administer medication to a resident who has been scanned and matches the information on the handset, effectively eliminating medication errors. 

Incomplete or inaccurate record-keeping 

Accurate and timely documentation of medication administration is essential to ensure resident safety and continuity of care. Unfortunately, care homes still experience frequent issues with incomplete or inaccurate records. Staff may forget to record a dose, fill in MAR charts at the end of a shift rather than immediately after administration, or provide vague entries for “as needed” (PRN) medications. 

These errors can lead to serious problems, including repeat dosing, missed treatments, and confusion during inspections or shift changes. Regulatory bodies like the CQC pay close attention to medication records, making good documentation not just a clinical priority but a compliance issue as well. 

To improve accuracy, staff should always record medication administration immediately after giving the dose, which is easy to do with ATLAS eMAR, which can be updated virtually in real-time. For PRN medications, the reason for use and outcome should also be documented clearly. Introducing eMAR systems can streamline the process, reduce human error, and provide a reliable audit trail. Regular internal checks or audits can help to catch and correct problems early. 

Not monitoring for side effects or drug interactions 

Administering medication is only one part of safe medication management. Monitoring the resident afterwards is just as important, particularly when they are starting a new prescription or taking multiple medications. Unfortunately, care staff may overlook signs of side effects or interactions, especially in busy environments. 

Some medications may cause drowsiness, dizziness, confusion, or stomach upset, which can lead to increased falls, changes in behaviour, or worsening of other conditions. In residents with dementia, the signs of a negative reaction may be mistaken for progression of the condition. 

To address this, care homes should schedule regular medication reviews with pharmacists or GPs. These reviews are essential for residents on multiple medications, and help ensure each prescription is still appropriate and safe. Staff must be trained to identify early signs of side effects or adverse interactions and to report them promptly. Open communication between carers, healthcare professionals, and families supports early intervention and better outcomes for residents. 

Eradicate preventable errors in medication management 

Medication errors in care homes are unfortunately common, but they are largely preventable. Through appropriate training, clear procedures, and the use of digital tools where available, care homes can significantly reduce the risks involved. Equally important is creating a culture of safety, where staff feel confident to report concerns, double-check information, and ask for clarification when needed. 

By prioritising accurate record-keeping, following established medication protocols, and maintaining strong communication with healthcare professionals, care teams can ensure that residents receive the right medications at the right time, safely and consistently. This not only improves compliance with regulations, but also upholds the dignity, health, and wellbeing of every individual in their care. 

Medication safety is more than a task, it’s a cornerstone of compassionate, person-centred care.