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Care homes’ use of medicines study: Prevalence, causes and potential harm of medication errors in care homes for older people

This article in Quality and Safety in Healthcare, the leading journal for clinical safety research and a member of the BMJ family of journals, discusses the first study to research the prevalence and causes of medication errors in care homes.

The research study addressed a key issue related to care of ageing populations. Buckle led the ergonomics/human factors components and directed the complex systems analysis research elements and the analysis of the causes of the errors identified. Using a mixed methods methodology (qualitative, quantitative epidemiology, ergonomics task analyses and risk assessments), the research team triangulated and identified new causes of errors in 256 residents recruited in 55 homes.

The research identified an alarmingly high prevalence of errors: 178 (69.5%) of residents had suffered one or more errors. The mean number per resident was 1.9 errors. Contributing factors deduced 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.

The study identified many components of the care system that are currently deficient and that could benefit from design improvements. Medication administration in particular requires significant improvement as the system is currently poorly designed and prone to alarmingly frequent errors. The research led immediately to a nationwide alert by the National Patient Safety Agency. Additional publications related to this work included a full report to the Department of Health and 10 peer-reviewed publications/conference papers.