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Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people
  1. N D Barber1,
  2. D P Alldred2,
  3. D K Raynor2,
  4. R Dickinson2,
  5. S Garfield1,
  6. B Jesson1,
  7. R Lim3,
  8. I Savage1,
  9. C Standage2,
  10. P Buckle3,
  11. J Carpenter4,
  12. B Franklin1,5,
  13. M Woloshynowych5,
  14. A G Zermansky2
  1. 1
    Department of Practice and Policy, School of Pharmacy, London, UK
  2. 2
    School of Healthcare, University of Leeds, Leeds, UK
  3. 3
    Robens Centre for Public Health, University of Surrey, Guildford, Surrey, UK
  4. 4
    London School of Hygiene and Tropical Medicine, London, UK
  5. 5
    Imperial College Healthcare NHS Trust, London, UK
  1. Correspondence to Professor N D Barber, Department of Practice and Policy, School of Pharmacy, Tavistock House, Tavistock Square, London WC1H 9JP, UK; n.barber{at}


Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.

Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.

Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.

Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

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  • Funding The study was funded by the Patient Safety Research Programme of the Department of Health. The authors are independent of the funders. The sponsor approved the study design. All authors had full access to all the data and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests None.

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