MANAGINGANDADMINISTERING

MEDICATIONINCAREHOMESFOROLDER
PEOPLE

Areportfortheproject:Workingtogetherto
developpracticalsolutions:anintegrated
approachtomedicationincarehomes.
CentreforPolicyonAgeing
October2011
RevisedApril2012
Managingandadministeringmedicationincarehomesforolderpeople

Contents

Page
Keymessages 1
1 Introduction 4
2 Theextentoftheproblem 1
3 Sourcesofmedicationadministrationerror 7
4 Monitoringmedication 11
5 Theuseoftechnologyandotheraids 11
6 Regulations,standards,guidanceandcodesofpractice

13
7 Makingadifference 21
8 Concludingcomments 25
9 Referencesandfurtherreadings 27

Keymessages
1. Olderpeopleincarehomesareamongthemostvulnerablemembersofoursociety,relianton
carehomestaffformanyoftheireverydayneeds.Acombinationofcomplexmedicalconditions
mayleadtotheneedtotakemultiplemedicationswithcarehomeresidentstaking78
medicationsonaverage.Thispolypharmacyinturnincreasestheriskofmedicationerror.
Medicationerrorsmayoccurasaresultofafailureinprescribing,dispensing,administeringor
monitoringmedication.
2. Thisreportfocusesontheadministeringofmedicationincarehomes.Itlooksattheprevalence
oferror,commoncausesandhowthesecanbeaddressed,throughsimple,lowcostchangesin
practice,appropriatetrainingandmoresubstantivechangesincarehomesystems.
3. Respectfortheolderresidentandtheirdignityandrightsasanindividualshouldremainatthe
heartofthemedicationprocesswithmedicationbeingadministeredonbehalfoftheresident
ratherthantotheresident.
4. Theprincipleofthe5Rsofcorrectmedicationadministrationincarehomesremainssound,
rightresident,rightmedicationandrightdosebytherightrouteattherighttime.Inaddition,
thewelfare,rightsandvoiceoftheolderpersonreceivingmedicationhavetoremainatthe
heartoftheprocess.
5. Thecarehomesuseofmedicines(CHUMS)studyobservedthaterrorsoccuron8.4%of
medicationadministrationevents.Thatwouldmeanthatacarehomeresidentbeing
administeredmedicationthreetimesadaywouldbe99.9%certaintoreceiveatleastone
medicationadministrationerroreverymonth.
6. Themostcommontypesofmedicationadministrationerrorareincorrectcrushingof
medication,notsupervisingtheintakeofmedicationparticularlyforresidentswithdementia,
incorrecttiming,omissionsandwrongdose.
7. Errorsaremorecommoninthemorningthanlaterintheday.
8. Thereisconflictingevidenceofwhethermedicationadministrationerrorsaremorelikelyin
residentialornursinghomecare,andthereisnoobviousrelationshipbetweenmedication
errorsandtypeofcarehomeownership,public,privateorvoluntary.
9. Inhalersandliquidmedicationsaremuchmorelikelytogiverisetomedicationerrorsthan
tabletsbutitisunclearwhethermonitoreddosagesystems(MDS)areinherentlysafer.
Antibioticsmaybeparticularlypronetoerrorwithanumberofdosesbeingmissedoverthe
courseoftreatment.
10. Acommonlycitedcauseformedicationerrorsisinterruptionsduringthepreparationand
administrationofdrugs,withinterruptionstakinguparound11%ofmedicationadministration
time.Interruptionsareusuallybyothercarehomestaff.Anothercommonlycitedcauseisa
breakdownincommunicationaboutmedicationbetweenGP,hospital,pharmacyandcarehome
2

duringaperiodoftransition,whentheresidentfirstentersacarehomeorreturnstothecare
homeafteraperiodinhospital.
11. Residentsshouldbeinvolvedinthemedicationprocess.Amentallyalertresident,orfully
informedrelativeorfriendmaybethefinalcheckagainstmedicationerrorinthecarehome,but
manyresidentsarepassiveinthemedicationprocesssayingIjusttakewhatImgiven.
12. Theadministeringofmedicationsincarehomeiscurrently(October2011)coveredbyregulation
13oftheHealthandSocialcareAct2008(RegulatedActivities)Regulations2010and
complianceismonitoredbytheCareQualityCommission.
13. Standardsandguidanceonthehandlingandadministeringofmedicationincarehomesare
availablefromanumberofsources.TheRoyalPharmaceuticalSociety(ofGreatBritain)[2007]
andtheNursingandMidwiferyCouncil[2008]havepublishedstandardsandguidanceon
medicationincarehomes.TheRoyalPharmaceuticalSociety[2011]hasalsopublishedguidance
ongoodpracticewhenpatients/residentstransferbetweencareproviders.Manyprimarycare
trustshavepublishedguidanceandtemplatesofpoliciesandproceduresforcarehometo
adopt,someofwhicharelistedinthisreport,andtheSocialCareAssociation[2008]has
outlinedtwelveprinciplesofgoodpracticethatequallyapplytocarehomes.
14. Simple,lowcostoptionsthatmayreducethechanceofadministrationerror
Distributefreshwatertoallresidentsbeforethemedicationround
Avoidinterruptionsbythecareradministeringmedicationwearingabrightlycoloured
sleevelessjacketindicatingthatmedicationisbeingdispensedandrequestingtheyshould
notbedisturbed
Withtheagreementoftheprescriber,administermedicationthatdoesnotneedtobe
administeredinthemorning,laterintheday
EnsurethatproceduresareinplacetorecordtheuseofPRN(asrequired)medicationonthe
medicationadministrationrecord(MAR)chartsothatstocklevelsaremaintained
Wherethisisnotalreadythecase,requestthatmedicine/medicationadministrationrecord
(MAR)chartsbesuppliedinaprintedformtoavoidincorrecttranscribinganddifficultto
readhandwriting
Requestthatthepharmacistsuppliesacopyoftheoriginalmedicationinformationleaflet
(indications,contraindicationsandmethodofadministration)whenamedicationisfirst
suppliedtoanindividualresidentaspartofamonitoreddosagesystem
15. Othersuggestedchanges.
Givingmedicationtothewrongresidentisrarebutseriouswhenitoccurs.Onestudyfound
that,overathreemonthperiod,overonehalfofresidentswereexposedtoanattemptto
givemedicationtothewrongresident.Attachingaphotographoftheresidenttothe
3

medicationadministrationrecord(MAR)chartisnotanewsuggestionbutmayhelptoavoid
sucherrors.
Staffawarenessiskeytoavoidingerrors.Aprogrammeofinitialandrefreshertrainingin
suchthingsastheimportanceoftimingandhowtohandleinhalersshouldbeestablished.
Trainingmaybeavailablethroughlocalcommunitypharmaciesorthroughcertified
programmesestablishedbylocalauthoritiesorPCTs.
Theuseofmedicationtrolleysmaybemoreappropriateforhospitalwardsthancarehomes.
Thereisevidencethatstoringaresidentsmedicationinalockedcupboardintheresidents
ownroom,insteadofusingatrolley,mayreducethechanceoferror.
GPsmakefewhomevisitsandusuallyconsultpatientsmedicalnotesonthecomputer
systematthesurgery.Carehomeresidents,ontheotherhand,areoftenunabletovisitthe
GPandrequireavisittothecarehome.WherepossibletheestablishmentofanITlink
betweenthecarehomeandthesurgerycomputersystem,sothatGPscanconsultpatient
noteswhileonsite,mayhelptoreducemedicationerrors.
16. Inadditiontotheindividualpracticalsuggestionsabovethereisaneedtostrengthen
medicationsystemswithinthehome.Thereshouldbeanindividualinthecarehomewhotakes
responsibilityforthemedicationprocessesandtheirimplementation.Inasmallcarehomethis
maybetheregisteredmanagerbutinalargerhome,whilethemanagerretainsultimate
responsibility,thismaybedelegatedtoasuitablyqualified,responsibleperson.Itisalso
recommendedthatanindependentreviewofthecarehomesprocessesbecommissionedfrom
anoutsidepersonforexampleapharmacist,toensurethatinternalprocessesand
communicationwithGPs,pharmacistsandthePCTiseffective.
17. Technologybasedsolutionshavebeenshowntoreducemedicationadministrationerrors,but
theywillonlybeembracedbycarehomestaffiftheyarereliable,easytouseanddonotadd
significantlytostaffworkloadforaparticulartask.

1. INTRODUCTION
Mostolderpeopleincarehomesaretakingseveralmedicationsanderrorsmayariseatthepointof
prescribing,dispensing,administeringormonitoringthatmedication.Recentresearchhas
highlightedtheunacceptablyhighlevelsofmedicationerror.
Thisreport,whichfocusesontheadministeringofmedicationincarehomes,waspreparedforthe
Workingtogethertodeveloppracticalsolutions:anintegratedapproachtomedicationincare
homesprojectfundedbytheDepartmentofHealth.Thereport,whichisintendedforcarehome
owners,managersandseniorstaff,drawstogetherinformationfromavarietyofsourcestodescribe
theextentoftheproblem,identifycommoncausesandsuggestsimpleandpracticalwaysof
reducingtheriskoferrorwhenadministeringmedication.
Theroleofcarehomesandthetypeofcareprovidedhasbeenchanging.Residentialandnursing
homecareforolderpeoplehasdevelopedfrombeinganalternativeformofaccommodationin
olderagetoaprovisionmainlyforthefrailestolderpeoplewithhighsupportneedsorforthose
withmentalhealthconditionsincludingdementia,towardstheendoflife.Thenumberofcarehome
placeshasbeendeclining.In2011,thenumberofplacesavailableinresidentialandnursingcarein
Englandwasfewerthan470,000
1
fallingfromapeak,in1996,of575,500fortheUKasawhole,as
moreandmoreolderpeoplearebeingcaredforathome.
2
Carehomeresidentsareoftenthose
whocannolongerbecaredforathomebecausetheyhavesevereormultiplemedicalconditions.
Theaveragelengthofstayinacarehomeisgettingshorterand,ifpresenttrendscontinue,willbe
lessthanoneyearby2015.
2

Olderpeopleincarehomesareamongthemostvulnerablemembersofoursociety.Oldercare
homeresidents,aregenerallyunabletoleavethecarehomeunaidedtovisitaGPorhospitalandas
aresultofcomplexmedicalneedsare,onaverage,taking78medications.Thismakesolder
residentsparticularlydependentonthesupportofcarehomestaffwhentakingmedication.The
propermanagementandadministeringofmedicationsisakeypartofgoodcareforolderpeoplein
carehomesbutthereisevidencethaterrorsintheadministrationofmedicationarenotuncommon.

2. THEEXTENTOFTHEPROBLEM
Theimportanceofadoptingappropriatemedicationproceduresincarehomeswashighlightedbya
keyresearchreport,thecarehomeuseofmedicines(CHUMS)study
3
.Thisstudyfoundthatcare
homestaffmayspendasmuchas4050%oftheirtimeonmedicationrelatedactivitieswitherrors
occurringon8.4%ofobservedmedicationadministrationevents.Thatwouldmeanthataresident
receivingmedicationthreetimesadaywouldhavean84%chanceofreceivingatleastone

1
CareQualityCommission,2011
2
CentreforPolicyonAgeing,2011
3
Alldred,Barber,Carpenteretal,2009
medicationadministrationerroreveryweekandwouldbevirtuallycertain(99.9%chance)of
receivingatleastonemedicationadministrationerroreverymonth.
AUKevaluationofabarcodemedicationmanagementsysteminlongtermresidentialcare
4,5

identified67medicationadministrationeventsperresidentperdaywitharound2errors
preventedbythesystemperresidentpermonth.Themostcommonerrorwasgivingmedicationat
thewrongtimealthough,overathreemonthperiodoveronehalfofresidents(52%)wereexposed
toanattempttogivemedicationtothewrongresident.
Notallmedicationerrorsoccurinthecarehome.Medicationerrorsmayoccuratthetimeof
prescribing,dispensingoradministeringthemedicationorthroughinadequatemonitoringofacare
homeresidentfollowingmedicationthatrequiresmonitoring.[Figure1]Whilecarehomestaffmay
onlyhavedirectresponsibilityforadministeringandmonitoringmedication,goodcommunication
betweencarehomestaffandtheprescribingGPorhospital,thedispensingpharmacistandother
healthcareprofessionalscanbejustasimportantinreducingthechanceoferrors.Thecarehome
useofmedicines(CHUMS)study
3
foundthatonehalf(50%)ofthesecommunicationerrorswere
betweenthecarehomeandthepharmacy.
Figure1
Source:CHUMSstudy,2009

Therearesignsthatmedicationstandardsincarehomeshaveimprovedoverthepastdecadebut
thereisstillroomforfurtherimprovement.Underitspreviousregulatoryframework,theCare

4
Szczepura,WildandNelson,2010
5
Szczepura,WildandNelson,2011
5

StandardsAct2000,theCareQualityCommission(CQC)reportedthattheproportionofcarehomes
forolderpeoplereachingorexceedingthenationalminimumstandardonmedicationhadrisen
from45%in20023to70%in20089,anundoubtedimprovementbutleaving30%ofhomesstillnot
reachingthestandard.

Figure2
PercentageofcarehomesforolderpeoplemeetingNationalMinimumStandardsonmedication
Source:CareQualityCommission

Figure3

Morerecently,undertheHealthandSocialCareAct2008regulatoryframework,CQCfoundthat,
betweenOctober2010andJuly2011,theproportionofallcarehomesachievingfullcompliance
withOutcome9,onmanagementofmedicines,was61%forcarehomeswithnursingand72%for
carehomeswithoutnursing[Figure3],leavingroughly30%40%ofhomesnotfullycompliant.
6

Inasurveyofcarehomescarriedoutin2010/2011butnotpublisheduntil2012
6
theCareQuality
Commissionreportedtheextenttowhichmedicationpolicieswereinplaceincarehomes.Most
homes(93%)alwaysrecordmedicineserrorsandhavearrangementsinplacetolearnfromthose
errorsbutwhile85%ofhomeshaveapolicyonhomely(overthecounter/nonprescription)
medicinesand84%keptananticoagulationrecordonly57%ofhomeshaveapolicycovering
decisionstoadministerPRN(asrequired)medication.Although39%ofhomesreportedthatgetting
medicationtoresidentsontimewassometimesoroftenaproblem,lessthanonehalfofhomes
(49%)recordtheactualtimeofadministrationofmedicines.

3. THESOURCESOFMEDICATIONADMINISTRATIONERRORS
Commoncauses
AstudyofDutchcarehomes
14
foundthemostcommoncausesofmedicationadministrationerror
wereincorrectcrushingofmedication,notsupervisingtheintakeofmedication,particularlyfor
residentswithdementia,andincorrecttimingmeasuredasmedicationbeingoveronehourearlyor
late.TheCHUMS
7
studyfoundthatnearlyonehalf(49.1%)ofadministrationerrorswereomissions
andmorethanonefifth(21.6%)werewrongdose.Theyidentifiedareasforpriorityattentionas
theMedicationAdministrationRecord(MAR)chartandinparticulardiscontinueddrugs,the
medicationroundandinparticularinterruptions,andcommunicationbetweenthepharmacyand
thecarehome.
Typeofcarehome
Thereisconflictingevidenceofwhether,forolderpeople,residentialhomesorcarehomeswith
nursingperformbetterinthehandlingandadministrationofmedicines.CQCreportedthat,between
2002and2009,residentialhomesinitiallyperformedlesswellthannursinghomesinmeeting
nationalminimumstandardsbutimprovedsubstantiallyovertheperiodand,by2009,werevery
similarintheiroutcomes(Figure2).However,Inthedifferentlyformulated201011CQCmeasures,
nursinghomesoverallperformedlesswellthancarehomeswithoutnursing(Figure3).Thisisat
variancewiththeCHUMsstudy
8
whichobservedthatolderpeopleinresidentialcare,received
twiceasmanymedicationadministrationerrors(MAE)asolderresidentsinnursingcareeven
thoughtheymadeupjust54%oftheresidentsstudied.Itishoweverinlinewitha2010studyofthe
effectivenessofpharmacymanagedbarcodemedicationmanagementsystems
9
whichfoundthat
theriskofapotentialmedicationadministrationerrorwas10%higherforresidentsinanursing
homethanforthoseinresidentialcare.
ArecentUSstudy
10
foundthatalthoughtherenodirectassociationbetweenthetypeofownership
ofahome(public/voluntary/private)andthenumberofmedicationerrors,anotforprofithome

6
CareQualityCommission,2012
7
Barber,Alldred,Raynoretal,2009
8
Alldred,Barber,Carpenteretal,2009
9
Szczepura,WildandNelson,2010
10
Lane,2010
8

thatwaspartofachainhadonlyhalfthelevelofmedicationerrorscomparedwithaforprofithome
thatwasnotpartofachain.
Stafftrainingandqualifications
Commonsensewouldindicatethatappropriatestafftrainingintherole,effectsandproper
administrationofmedication,forexampleinthecorrectuseofinhalers,wouldpromotebetter
understandingamongcarehomestaffandreducethechancesofmedicationerror.TheCareHomes
UseofMedicines(CHUMS)study
8
highlightedthisissuestatingthatstaffnumbers,skillsetsand
trainingmaybeimportantdeterminantsinmedicationadministrationerror.Trainingintheuseof
inhalersandtheimportanceofcorrecttimingofmedicationwereparticularlymentioned.
StudiesintheUSA
11,12
havefoundconflictingevidenceaboutwhetherthelevelofqualificationof
carehomestaffhasanyinfluenceonmedicationerrors.AstudyinDutchcarehomes
14
,however,
foundthatcarehomeworkerswithmoreexperiencemadefewererrorsandarecentstudyinthe
USA
13
foundthat,inassistedliving,workerswithbettertraininghadonlyhalfthemedication
administrationerrorrateofthosethatwerelesswelltrained.
Timeofday
Thereareindicationsthatmedicationadministeredinthefirsthalfoftheday(7amto2pm)istwice
aslikelytogiverisetoerrorsasmedicationadministeredintheevening
14
.Thereasonsforthisare
unprovenbutmayrelatetothemorningbeingabusierpartofthecarehomeday.
Formulationanddeliveryprocess
Crushedmedicationisnearlyeighttimesmorelikelythantabletstogiverisetoamedication
administrationerror
14
.AfollowupanalysisoftheCHUMSstudydata
15
foundthatinhalersand
liquidmedicineswereassociatedwithsignificantlyincreasedoddsofanadministrationerror.
Inhalersweretheworstsourceoferrorbeingover20timesmorelikelythanMDStabletstogiverise
toanerrorintheadministrationprocess.Topical(egeyedrops),transdermal(creams,ointments
etc)andinjectablemedicineswerearound14timesmorelikelytogiverisetoanerrorthanMDS
tabletsbut,becausethenumbersweresmall,theresultswerenotstatisticallysignificant.Common
faultswithliquidswereinaccuratemeasuringandnotshakingthebottle.

Antibiotics
Theadministeringofantibioticsincarehomesmaybeparticularlypronetoerror.AstudyinWales
16

oftheadministrationofantibiotics(afixednumberofdosesadministeredatregularintervals)found
thatnearlyonefifth(18%)wereadministeredinappropriately,withanoverrunofmorethanone

11
ScottCawiezelletal,2007
12
Hughes,WrightandLapane,2006
13
Zimmermanetal,2011
14
VandenBemtetal,2009
15
Alldredetal,2011
16
Hinchliffe,2010referencingHussainandWalker,1999
9

dayobserved,indicatingthatdoseshadbeenmissed.A2009studyinDutchnursinghomes
17
found
thatantibioticswereovertentimesmorelikelytogenerateanadministrationerrorthanastandard
gastrointestinalmedication.
Interruptions
Whenaskedaboutbarrierstosafemedication,themostcommonbarriertothesafepreparationof
medicationscitedbynursesinBelgiancarehomeswasinterruptionswhilepreparingand
administeringmedication
18
.Interruptionswerecitedasabarrierbyover40%ofnurses.ACanadian
timemotionstudyinalongtermcarefacility
19
foundthatinterruptionsaccountedfor11.5%of
medicationadministrationtimewithatleastoneinterruptionin79%ofmedicationrounds.AUK
studyofhospitalmedicationrounds
20
foundsimilarresultswithinterruptionstakingup11%ofthe
timeoneachmedicationround.TheUKCHUMSstudyofmedicationincarehomes
21
,described
interruptionsasfrequentorconstant,particularlyduringthemorningdrugsround.Theiranalysis
oferrorreportsidentifiedinterruptionsasthemostsignificantcontributortoerroronthe
medicationroundwithaninterruptionoccurring,onaverage,every15minutes.Over60%of
interruptionswerebyotherstaffwithover90%ofstaffinterruptionbeingaboutoperationalissues.
Fewerthan9%ofinterruptionswereverbalrequestsfromresidents.
Transitionsandcommunication
Itiswidelyacknowledgedthatresidentsmaybeparticularlyatriskofmedicationerrorduringa
periodoftransition,eitherwhentheresidentfirstentersacarehomeorwhenaresidentreturnsto
acarehomeafteraspellinhospital.Thismaybeasaresultofpoorcommunicationabout
medicationbetweentheresidentsownGPandthecarehome.Followingaperiodinhospital,
medicalnotes,includingnotesofanychangeinmedication,maybesenttotheresidentsGPand
notnecessarilyimmediatelyfollowtheresidenttothecarehome.Overtwothirdsofthenursing
homesina2010USstudy
22
reportedamedicationerrorduringthefirstsevendaysofaresidents
admission.TheCHUMSstudy
23
intheUKfoundthat29%ofcommunicationrelatedmedication
errorswerebetweenthecarehomeandtheGPsurgeryalthoughthisrelatedtoallresidentsnotjust
neworreturningresidentsandwaslessthanthe50%ofcommunicationrelatedmedicationerrors
thatwerebetweenthecarehomeandthepharmacy.
AnAustralianstudy
24
foundimprovedhealthoutcomesforresidentsforwhom,ontransferfrom
hospital,thecarehomewassentamedicationtransfersummaryandtherewasapharmacistled
medicationreviewwithin1014daysofadmissiontothecarehome.

17
VandenBemtetal,2009
18
Dillesetal,2011
19
Thomsonetal,2009
20
Kreckleretal,2008
21
Alldred,Barber,Carpenteretal,2009
22
Lane,2010
23
Alldred,Barber,Carpenteretal,2009
24
Crottyetal,2004reviewedinLaMantiaetal,2010
10

Theroleoftheresident
Residentsandtheirrelativesshouldbeencouragedtobeinvolvedandawareofthemedication
processwithselfmedicationbyresidentswheneverpossible.Amentallyalertresident,orrelatives
andfriendswhoknowtheresidentwell,canactasafinalcheckagainstmedicationerrors.National
policyemphasisestheinvolvementoftheserviceuser.NationalMinimumStandards,followingthe
CareStandardsAct2000andoperationaluntiltheimplementationoftheHealthandSocialCareAct
2008,statedServiceusers,whereappropriate,areresponsiblefortheirownmedication.The
replacementregulations,whilelessprescriptive,emphasisedtheinvolvementoftheresidentand
relativesandfriends.Peoplewhousetheservices,whereverpossible,willhaveinformationabout
themedicinebeingprescribedmadeavailabletothemorothersactingontheirbehalf.
TheWorkingtogethertodeveloppracticalsolutions:anintegratedapproachtomedicationincare
homesprojecthasdevelopedaResidentsChartertopromoteabetterunderstandingofhow
residentscanandshouldbeinvolvedintheadministrationoftheirmedication(seesection6.4).
A2009Dutchstudyofmedicationerrorsinnursinghomes
25
foundDrugadministrationerrorsare
lesslikelytobeprevented,becausetheyoccurinthelaststageofthedrugdistributionprocess.This
isespeciallythecaseinnonalertpatients,aspatientsoftenformthefinalbarriertopreventionof
errors.
Althoughamentallyalertresidentshouldbethelastcheckagainstmedicationerrors,residents
oftenaccept,withoutquestion,thecontroloftheirmedicationbycarehomestaff.A2009studyof
residentsofnursinghomesinNorthernIreland
26
reportedthatresidentsweregenerallyadherentto
medicationandhadlittleinvolvementineithertheprescribingoradministeringprocess.One
residentsaidIjusttakewhatIamgiven.
Thelackofcommunicationandinformationsharingwithrelativesandcarers,aroundmedication,
wasoneofthemainissuesraisedasacauseofmedicationerrorsincarehomesina2011study
27
of
theviewsofrelativesandcarers.Residents,relativesandcarers,ifmorefullyinvolvedandinformed,
cancontributebettertotheidentificationandeliminationofpotentialmedicationerrors.
PRN(prorenatawhenorasrequired)medication
Becauseasrequiredmedicationisonlyreorderedwhenstocklevelsrequireit,itdoesnotformpart
oftheregulareverytimemedicationorderingadministeringreorderingcycleandcannotbepart
ofamonitoreddosagesystem.Itisparticularlypronetolapsesinkeepingadequatesuppliesofthe
medicationinreserveandisaparticularchallengeforrecordkeeping.
Prescribingmedicineasrequired,forexampleforlaxativesorsedativesisaneffectivewaytotreat
aresidentsufferingfromanacuteorirregularcondition.Thebenefitsofflexibilityarealsoopento
thedisbenefitsofmisuse.PRNmedicationshouldonlybeofferedwhenrequired,iewhen
symptomsareexhibited,andnotrestrictedtothenormalmedicationround.Aspecificplanfor

25
VandenBemtetal,2009
26
HughesandGoldie,2009
27
TheHealthFoundation,2011
11

ons
32
.

administrationofthePRNmedicationmustberecordedandinformationaboutwhy,whenandhow
themedicationshouldbeadministered,togetherwithanyrestrictions(forexamplemax4dosesin
24hours),soughtfromtheprescriber,pharmacistorotherhealthcareprofessionalandrecordedon
theplanwhichshouldbekeptwiththeregularmedicineadministrationrecord(MAR)chart.
28
PRN
medicationwillbeinitsoriginalpackagingandnotpartofamonitoreddosagesystem(MDS).A
recordofanyamountsadministeredwithdatesandtimesshouldberecordedontheMARchartand
theamountleftshouldberecordedoneachnewMARcharttoensurethemonitoringofstocklevels
andtimelyreordering.
29

4. MONITORINGMEDICATION

Manymedicinesmaybesafelyprescribedwithoutcarefulintensivefollowupmonitoringbutothers,
whereadverseunintendedsideeffectsarelikelyorthathaveahighriskoftoxicityorwheredosage
needstobeadjusted,maynecessitateregularandfrequentmonitoringofaresidentsprogress.The
CHUMS
30
studyreportedthattheharmscoreformonitoringerrorswashigherthanforotherforms
oferror,whichreflectstheimportanceofmonitoringwhenitisrequired.Themostcommon
monitoringerrorsreportedintheCHUMSstudywerefordiuretics(55%)andACEinhibitors(16%).
While37%ofpreventabledrugrelatedmorbidityisassociatedwithalackofmonitoringof
drugs
31
,withoverthreequartersinvolvingACEInhibitors,diureticsaccountfor16%ofmedicine
relatedhospitaladmissi

ArecentstudyinBelgiannursinghomes
33
ofbarrierstosafemedicationmanagementfoundthat
nursesfeltthatbarrierstosafetyinmonitoringthesideeffectsofmedicationwerestrongerthan
barriersintheadministrationofthemedication.Nursesratedhighly,asbarrierstosafetyin
monitoring,theadverseeffectoflackofinformationfromthephysician,lackofcommunication
aboutsideeffects,lackofknowledgeaboutboththerapeuticeffectsandsideeffects,difficultyin
communicatingwiththephysicianandlackoftimetoperformthetaskwithcare.

5. THEUSEOFTECHNOLOGYANDOTHERAIDS
MonitoredDosageSystems(MDS)
MonitoredDosageSystems(MDS),inwhichthemedicationsforanindividualresidentataparticular
timearerepackagedbythepharmacist,areinwidespreaduseincarehomes.TheCHUMSstudy
34

foundarangeofviewsaboutMDS.SomepharmacistsfeltthatMDSmadeiteasierforcarehome
stafftoadministermedicationsafelyandsystematicallywhileothersexpressedmorenegative

28
CareQualityCommission,2008
29
GloucestershireCareServices,2010,http://www.glospct.nhs.uk/chst/chst_medicines.html
30
Alldred,Barber,Carpenteretal,2009
31
Morrisetal,2004
32
Howardetal,2007
33
Dillesetal,2011
34
Alldred,Barber,Carpenteretal,2009
12

opinionsincludingtheviewthatMDSwerenotsafeastabletscouldnotbeidentified.One
pharmacistnotedthatwhenatabletwasdroppedthestaffwouldnothaveareplacement.Another
saidthatMDSencouragedstaffnottolookatthelabel.AfollowupanalysisoftheCHUMSdata
15

wasambivalentaboutwhetherMDSadministeredmedicationwassafer.Although,onthesurface,
errorrateswerebetterwithMDSadministeredmedication,themoreproblematicmedications,for
exampleliquidsandinhaleradministeredmedications,areoftennotpartoftheMDSsystemsso
comparisonwasnotoflikewithlike.Inadditionasrequired(PRN)medicationcannotbepartofthe
MDSsystem.ItisstillthereforeunclearwhetherornottraditionalMDSisinherentlysaferthan
originallypackagedmedication.ThereissomeevidencefromtheCHUMSstudy
34
thatsingletablet
MDSblisterpacksmaybesaferthanMDScassettebasedsystemsandsomemorerecentMDSblister
systemscanalsoaccommodateliquids.

Pharmacymanagedbarcodemedicationmanagementsystems
Barcodebasedmedicationadministrationsystemshavethepotentialofreducingmedication
administrationerrorsincarehomesbyconfirmingthatthecorrectmedicationisbeinggiventothe
correctresidentattherighttime.AUKevaluationofonesuchsystem
35
showeditseffectivenessin
avoidingalargenumberofcarehomemedicationadministrationerrorswhichwouldotherwisehave
occurred,butdidnotevaluatetheeaseofuseofthesystem.Hospitalbasedbarcodesystemslinked
toelectronicmedicationadministrationrecords(eMAR)havebeenshowntocompletelyeliminate
transcriptionerrors.
36

Althoughtechnologybasedsolutionshavebeenshowntoreducemedicationadministrationerrors,
theywillonlybeembracedbycarehomestaffiftheyarereliable,easytouseanddonotadd
significantlytostaffworkloadforaparticulartask.Carehomestaffwillfindworkaroundsfor
workflowblockagesperceivedasunnecessary,eveniftheseareintentionalsafetychecksintroduced
bythesystem.
37

Technologyisonlyacceptedwhenitworksproperlyandmakesaworkingtaskeasierormore
effective.A2008USstudyoftheuseofbarcodemedicationmanagementsystemsinhospitals
reportedthatnurseswereobservedtoworkaroundthesysteminanumberofwaysincluding
affixingpatientIDbarcodestothemedicationtrolley,andcarryingseveralpatientsprescanned
medicationsonthetrolley.Theneedforaworkaroundwascausedbyanumberofproblems
includingunreadablebarcodes,malfunctioningscanners,wornbatteries,poorwirelessconnection,
missingpatientwristbandsandnonbarcodedmedication.HospitalnursesoverrodeBCMAalerts
for4%ofpatientsand10%ofmedicines
38
.

35
Szczepura,WildandNelson,2010
36
Poonetal,2010
37
Vogelsmeier,HalbeslebenandScottCawiezell,2008
38
Koppel,Wetterneck,TellesandKarsh,2008
13

6. REGULATIONS,STANDARDS,GUIDANCEANDCODESOFPRACTICE
Themanagementandadministrationofmedicinesincarehomesiscurrently(October2011)
coveredbyregulation13oftheHealthandSocialCareAct2008(RegulatedActivities)Regulations
2010
39,40.
Thisstatesthat
Theregisteredpersonmustprotectserviceusersagainsttherisksassociatedwiththeunsafeuse
andmanagementofmedicines,bymeansofthemakingofappropriatearrangementsforthe
obtaining,recording,handling,using,safekeeping,dispensing,safeadministrationanddisposalof
medicinesusedforthepurposesoftheregulatedactivity.
Inmakingthearrangementsabovetheregisteredpersonmusthaveregardtoanyguidanceissued
bytheSecretaryofStateoranappropriateexpertbodyinrelationtothesafehandlinganduseof
medicines
Thespecifiedoutcomeoftheregulationisthatpeoplewhousetheservices:
Willhavetheirmedicinesatthetimestheyneedthemandinasafeway
Whereverpossiblewillhaveinformationaboutthemedicinebeingprescribedmade
availabletothemorothersactingontheirbehalf

Thisisbecauseproviderswhocomplywiththeregulationswill:
Handlemedicinessafely,securelyandappropriately
Ensurethatmedicinesareprescribedandgivenbypeoplesafely
Followpublishedguidanceabouthowtousemedicinessafely.

CompliancewiththeregulationsismonitoredbytheCareQualityCommission.Dependingonthe
circumstances,thehandlingofcontrolleddrugsmaybefurtherregulatedbytheMisuseofDrugsAct
Regulations2001.
AnumberoforganisationsincludingtheRoyalPharmaceuticalSocietyofGreatBritainandthe
NursingandMidwiferyCouncilhaveproducedstandardsandguidancefortheuseofmedicines.
Manypointsaredirectlyrelevanttocarehomes,althoughtheterminologyofpatientratherthan
residentandthenamedstaffinvolvedmaysometimesdiffer.Themainpointsaresummarisedbelow
forconvenience.
The2011projectWorkingtogethertodeveloppracticalsolutions:anintegratedapproachto
medicationincarehomeshasalsodevelopedaframeworkguide:Makingthebestuseofmedicines
acrossallcaresettingswhichhighlightsexamplesofgoodpracticeformanagers,healthstaffand
residents.(Seesection6.4)

39
CareQualityCommission,2010a
40
CareQualityCommission,2010b
14

6.1. RoyalPharmaceuticalSocietyofGreatBritainGuidance
TheRoyalPharmaceuticalSocietyofGreatBritainhaspublishedguidance,Thehandlingofmedicines
insocialcare.
41
Theguidanceoutlineseightprinciplesrelatingtothesafeandappropriatehandling
ofmedicineswhichapplytoeverysocialcaresetting:
a) Peoplehavefreedomofchoiceinrelationtotheirproviderofpharmaceuticalcareand
services,includingdispensedmedicines
b) Carestaffknowwhichmedicineseachpersonhas,andthecareservicekeepsacomplete
accountofmedicines
c) Carestaffwhohelppeoplewiththeirmedicinesarecompetent
d) Medicinesaregivensafelyandcorrectly,andcarestaffpreservethedignityandprivacy
oftheindividualwhentheygivemedicinestothem
e) Medicinesareavailablewhentheindividualneedsthemandthecareprovidermakes
surethatunwantedmedicinesaredisposedofsafely
f) Medicinesarestoredsafely
g) Thesocialcareservicehasaccesstoadvicefromapharmacist
h) Medicinesareusedtocureorpreventdisease,ortorelievesymptomsandnottopunish
orcontrolbehaviour.
Iftheseprinciplesaretobeachievedthereneedstoberobustarrangementsforgoodpracticeand
communicationforallthoseinvolvedincludingGPs,hospitals,andcommunitypharmacistsaswellas
carestaff.
TheRPSGBguidelinesalsoindicatethatitisessentialthatcareworkerinresidentialcareforolder
peoplehaveawrittenpolicydocumentthatsetsout:
a) Howmedicinesareobtainedforresidents
b) Procedurestoassessselfadministration
c) Obtainingresidentsconsentifcareworkersgivemedicines
d) Howmedicinesarestored,centrallyandforselfadministration
e) Proceduresforadministration
f) Procedurestoassesscompetencetoadministermedicinessafely
g) Proceduresforcontrolleddrugs
h) Proceduresforprovidingmedicineswhenresidentstakeleave

41
RoyalPharmaceuticalSocietyofGreatBritain,2007
15

i) Whatrecordsareheld
j) Howtodealwithdrugerrorsandincidents
k) Howtodisposeofmedicines
l) Treatmentofminorailments
Theguidelinespointoutthatanalternativewaytostoremedicationisinindividuallockedmedicine
cupboardsordrawersinresidentsownrooms.Thiswouldbeessentialforselfmedicatingresidents
butcanalsobeusedinsystemswherecareworkersgivemedication.

6.2. NursingandMidwiferyCouncilStandards
TheNursingandMidwiferyCouncilStandardsformedicinesmanagement
42
,fornursesand
midwives,emphasisethefactthattheadministrationofmedicinesisnotjustamechanistictaskto
beperformedinstrictcompliancewiththewrittenprescriptionofamedicalpractitionerbutone
thatrequiresthoughtandtheexerciseofprofessionaljudgement.
Whenadministeringmedicationregisterednursesmust
becertainoftheidentityofthepatienttowhomthemedicineistobeadministered
checkthatthepatientisnotallergictothemedicinebeforeadministeringit
knowthetherapeuticusesofthemedicinetobeadministered,itsnormaldosage,side
effects,precautionsandcontraindications
beawareofthepatientsplanofcare(careplan/pathway)
checkthattheprescriptionorthelabelonmedicinedispensedisclearlywrittenand
unambiguous
checktheexpirydate(whereitexists)ofthemedicinetobeadministered
haveconsideredthedosage,weightwhereappropriate,methodofadministration,route
andtiming
administerorwithholdinthecontextofthepatientscondition(e.g.digoxinnotusuallyto
begivenifpulsebelow60)andcoexistingtherapiese.g.physiotherapy
contacttheprescriberoranotherauthorisedprescriberwithoutdelaywherecontra
indicationstotheprescribedmedicinearediscovered,wherethepatientdevelopsareaction
tothemedicine,orwhereassessmentofthepatientindicatesthatthemedicineisnolonger
suitable

42
NursingandMidwiferyCouncil,2008
16

makeaclear,accurateandimmediaterecordofallmedicineadministered,intentionally
withheldorrefusedbythepatient,ensuringthesignatureisclearandlegible;itisalsothe
responsibilityofthenursetoensurethatarecordismadewhendelegatingthetaskof
administeringmedicine.
Inaddition:
Wheremedicationisnotgiventhereasonfornotdoingsomustberecorded
AregisterednursemayadministerwithasinglesignatureanyPrescriptionOnlyMedicine
(POM),GeneralSalesList(GSL)orPharmacy(P)medication
InrespectofControlledDrugs:
Theseshouldbeadministeredinlinewithrelevantlegislationandlocalstandardoperating
procedures
ItisrecommendedthatfortheadministrationofControlledDrugsasecondarysignatoryis
requiredwithinsecondarycareandsimilarhealthcaresettings
Inapatientshome,wherearegistrantisadministeringaControlledDrugthathasalready
beenprescribedanddispensedtothatpatient,obtainingasecondarysignatoryshouldbe
basedonlocalriskassessment
Althoughnormallythesecondsignatoryshouldbeanotherregisteredhealthcare
professional(forexampledoctor,pharmacist,dentist)orstudentnurseormidwife,inthe
interestofpatientcare,wherethisisnotpossibleasecondsuitablepersonwhohasbeen
assessedascompetentmaysign.Itisgoodpracticethatthesecondsignatorywitnessesthe
wholeadministrationprocess.ForGuidance,goto:www.dh.gov.ukandsearchforSafer
ManagementofControlledDrugs:GuidanceonStandardOperatingProcedures
Incasesofdirectpatientadministrationoforalmedicationfromstockinasubstancemisuse
clinic,itmustbearegisterednursewhoadministers,signedbyasecondsignatory(assessed
ascompetent),whoisthensupervisedbytheregistrantasthepatientreceivesand
consumesthemedication
Aregisterednursemustclearlycountersignthesignatureofthestudentwhensupervisinga
studentintheadministrationofmedicines.
Selfadministration
Theregisterednurseisresponsiblefortheinitialandcontinuedassessmentofpatientswhoareself
administeringandhascontinuingresponsibilityforrecognisingandactinguponchangesina
patientsconditionwithregardstosafetyofthepatientandothers.

17

6.3. RoyalPharmaceuticalSocietygoodpracticeguidancefortransferbetweencareproviders
Oneofthetimesofgreatestriskofmedicationerrorforolderpeopleisatthepointsoftransition
betweenGPbasedhomecare,carehomecareandhospitalcare.
InJuly2011,theRoyalPharmaceuticalSocietypublishedKeepingpatientssafewhentheytransfer
betweencareprovidersgettingthemedicinesright
43
,atwopartgoodpracticeguideforhealthcare
professionals,providersandcommissioners.Althoughfocussingonhealthcareprofessionals,the
principlesofsoundinformationtransferareequallyapplicabletocarehomestaff.
Thisgoodpracticeguideoutlinedfourcoreprinciplesforhealthcareprofessionalsandthreekey
responsibilitiesfororganisationsprovidingcare,tominimisethechanceofmedicationerrorsarising
fromthetransferofresidents/patientsbetweencareproviders.
Fourcoreprinciplesforhealthprofessionals
1. Healthcareprofessionalstransferringapatientshouldensurethatallnecessaryinformation
aboutthepatientsmedicinesisaccuratelyrecordedandtransferredwiththepatient,and
thatresponsibilityforongoingprescribingisclear
2. Whentakingoverthecareofapatient,thehealthcareprofessionalresponsibleshouldcheck
thatinformationaboutthepatientsmedicineshasbeenaccuratelyreceived,recordedand
actedupon
3. Patients(ortheirparents,carersoradvocates)shouldbeencouragedtobeactivepartners
inmanagingtheirmedicineswhentheymove,andknowinplaintermswhy,whenandwhat
medicinestheyaretaking
4. Informationaboutpatientsmedicinesshouldbecommunicatedinawaywhichistimely,
clear,unambiguousandlegible;ideallygeneratedand/ortransferredelectronically.

Threekeyresponsibilitiesfororganisationsprovidingcare
1. Providerorganisationsmustensurethattheyhavesafesystemsthatdefinerolesand
responsibilitieswithintheorganisation,andensurethathealthcareprofessionalsare
supportedtotransferinformationaboutmedicinesaccurately
2. Systemsshouldfocusonimprovingpatientsafetyandpatientoutcomes.Organisations
shouldconsistentlymonitorandaudithoweffectivelytheytransferinformationabout
medicines
3. Goodandpoorpracticeinthetransferofmedicinesshouldbesharedtoimprovesystems
andencourageasafetyculture.

TheRoyalPharmaceuticalSocietyrecommendationsforthecorecontentsofarecordtobeused
whenpatientstransferbetweencareprovidersareshowninTable1.

43
RoyalPharmaceuticalSociety,2011
18

Table1RoyalPharmaceuticalSocietyrecommendedcorecontentsofrecordsformedicineswhenpatientstransferbetweencareproviders
Patientdetails Lastname,firstname,dateofbirth,NHSnumber,patientaddress
GPdetails GP/Practicename
Otherrelevantcontactsdefinedbythepatient Forexample
Consultantname,Usualcommunitypharmacist,Specialistnurse
Allergies Allergiesoradversereactionstomedicines
Causativemedicine
Briefdescriptionofreaction
Probabilityofoccurrence
Medications Currentmedicines
Medicinegenericnameandbrand(whererelevant)
Reasonformedication(whereknown)
Form
Dosestrength
Dosefrequency/time
Route
Medicationchanges Medicationstarted,stoppedordosagechanged,andreasonforchange
Medicationrecommendations Allowsfor:
Suggestionsaboutdurationand/orreview,ongoingmonitoringrequirements,adviceonstarting,discontinuing
orchangingmedicines
Requirementsforadherencesupport,forexamplecomplianceaids,promptsandpackagingrequirements
Additionalinformationaboutspecificmedicines,forexamplebrandnameorspecialproductwhere
bioavailabilityofformulationissues
Informationgiventothepatientand/orauthorised
representative
Ifadditionalinformationsuppliedtothepatient/authorisedrepresentativeontransfer.Forexample:
Patientadvisedtovisitcommunitypharmacistpostdischargeforamedicinesusereview(MUR)
Wherecapacity,sensoryorlanguagebarriers,howallnecessarysupportinformationhasbeengivento
authorisedrepresentative/carer
Personcompletingrecord Name,time,date,jobtitle
Contacttelephonenumberforqueries
Signature(ifpaperbased)

6.4. Otherguidance

FollowingtheChumsReport,inJanuary2010,theDirectorGeneral,SocialCare,LocalGovernment
andCarePartnerships,DavidBehanandtheChiefPharmaceuticalOfficer,KeithRidgesentaletterto
allDirectorsofAdultsSocialServices,StrategicHealthAuthoritiesandPrimaryCareTrustsinforming
themoftheconcerns.Asaresult,manyPCTsdevelopedteamstosupportcarehomes.

A2004reportbytheChiefPharmaceuticalOfficerattheDepartmentofHealth,Building
asaferNHSforpatientsimprovingmedicationsafety
44
,whilefocusingmainlyonmedical
establishmentsprovidesusefulguidanceforcarehomesonthesaferadministrationofmedicines
andthecausesofmedicationadministrationerror(Section3.3)aswellasorganisationaland
environmentalstrategiestoreducetherisk(Section6).Thereportsrecommendationsincludethe
useoftechnology,improvedlabellingandpackaging,afocusonproblemsthatarisewhen
individualstransferbetweencareprovidersandimprovededucationandtrainingformedication
safety.

AnumberofNHSPrimaryCareTrustshaveproducedguidesforcarehomesandothersonthe
handlingofmedication.InparticularGloucestershireCareServicesMedicinesmanagementforcare

44
Smith,JChiefPharmaceuticalOfficerDepartmentofHealth,2004
19

homesprovidesusefultemplatepoliciesforcarehomesontheordering,controlandstorageof
medicationandhomelyremediesaswellashowtodealwithrefusedordroppedmedication.
(http://www.glospct.nhs.uk/chst/chst_medicines.html)Otherexamplesareshownintable2but
therewillbemanymore.Allcanbedownloadedfromtheinternetaftersearchingbytitle.

Table2
NHSBuckinghamshire
andOxfordshireCluster
2011 Goodpracticeguidanceforcarehomestaffonmedicines
managementprocesseswithincarehomes
NHSCalderdale 2010 Medicinesgovernanceservicetocarehomes(CareHomes
Service)
NHSDoncaster 2008? Themanagementofcontrolleddrugsincarehomes
NHSGloucestershire
CareServices
2010 Medicinesmanagementforcarehomes
NHSLambeth 2008 Selfadministrationofmedicines
NHSPeterborough
CommunityServices
2011 Themanagementofmedicinesinresidentialcarehomes
policyandprocedure
NHSSheffield 2011 Communitypharmacyservicespecificationtosupportcare
homesinmedicinesmanagement
NHSShropshireCounty 2009 MedicationtobeadministeredonaPRN(whenrequired)
basisbyacareworkerinacarehomeenvironment
NHSShropshireCounty 2010 Medicinesmanagementincarehomesselfassessment
pack
NHSShropshireCounty 2011 Policy&proceduresforthehandlingofmedication
(Carehometemplatemedicationpolicy)
NHSSuffolk 2009 Theregulationofmedicationadministeredbycarers
NHSSwindon 2009 Medicinesmanagementguidanceforindependent
contractors

Medicinesmanagementforresidentialandnursinghomes:Atoolkitforbestpracticeandaccredited
learning
45
isabookwhichprovidesadeliberatelyeasytoread,simple,practiceguideandtraining
toolforcarehomestaff.

TheSocialCareAssociation,2008summaryguideMedicationadministrationinsocialcareoutlines
thekeyissuesassociatedwithordering,storage,administration,selfadministration,recordingand
recordkeeping,homelyremedies,controlleddrugs,sideeffects,errorsandthedisposalof
medicines.Aswellaslookingatlegalandethicalissuestheguideoutlinestwelveprinciplesofgood
practicethatareequallyapplicabletocarehomes.[Table3]

45
Lilley,LambdenandGillies,2007
Table3
1 Peoplehavefreedomofchoicein
relationtotheirmedicines
7 Thedignityandprivacyoftheindividualis
preservedwhenmedicinesaregiven
2 Carestaffknowwhatmedicineseach
individualistaking
8 Medicinesforindividualsareavailablewhen
needed
3 Medicinesaregivensafelyand
correctly
9 Thesocialcareservicehasaccesstoadvice
fromapharmacist
4 Medicinesarestoredsafely 10 Medicinesareonlyusedtocureorprevent
diseaseortorelievesymptomsandnotto
punishorcontrolbehaviour
5 Staffwhohelppeoplewiththeir
medicinesarecompetenttodoso
11 Unwantedmedicinesaredisposedofsafely
6 Acompleteaccountofmedicinesis
kept
12 Prescribedmedicinesarethepropertyof
thepersontowhomtheyhavebeen
prescribedordispensed

The2011projectWorkingtogethertodeveloppracticalsolutions:anintegratedapproachto
medicationincarehomeshasdevelopedagoodpracticeframeworkMakingthebestuseof
medicinesacrossallcaresettingsandaResidentsCharterMyMedicinesMyChoices.

Theframeworkincludesguidanceonwhatgoodpracticelookslike,withover50principlesofgood
practiceforcarehomemanagers,healthstaffandresidentsinthedispensing,supply,administering,
monitoringandreviewofmedicationacrossallcaresettings.Theframeworkalsoincludescase
studiesandexamplesofinnovationinpractice.

TheResidentsCharterisaimedatcarehomeresidentstohelpthemunderstandhowtheycanand
shouldbeinvolvedintheadministrationoftheirownmedication.

ResidentsCharterMyMedicinesMyChoices:Thisisacharterthathelpsyouunderstandyourrightsaboutthe
medicinesyoutakeandsayswhathelpyoushouldgetfromyourdoctor,pharmacistandcarestaff.
IaminformedaboutallmymedicinesandfullyinvolvedindecisionsconcerningthemandhowItake
them.
Myfamilyorrepresentativeis,withmypermission,alsoinformedofdecisionsinvolvingmymedicines.
Mydoctor,pharmacistandcarehomestaffworktogethertomakesureIreceivemymedicinessafely.
Thesepeoplewillalwaysactinmybestinterests.
ItisassumedthatIcanlookafterandtakemyownmedicinesandIcanaskforhelpfromthecarestaff.
Icanagreethatthehomecanmanagemymedicines.
MymedicinesarekeptinmyroomorwhereIwanttokeepthem.
Mycarehomekeepsrecordsofmymedicinesandmakessurethatthestaffcaringformeareawareofany
changes.
Allstaffhelpingmewithmymedicinesaretrainedandcompetent.Ifmyhealthchangesmymedicineswill
bereviewed.
MydoctorwillcheckIamontherightmedicinesatleasttwiceayear.TheywillalsobecheckedwhenIam
admittedtomycarehomeoronmyreturnfollowingastayinhospital.
IknowthatIcanaskmydoctortoreviewmymedicinesatanytime
20

7. MAKINGADIFFERENCE
7.1. Gettingitrightthe5Rsor5Cs
21

Whenadministeringmedicationincarehomesitisoftensaidthatthere
arefivethingsthatneedtoberight(5Rs)orcorrect(5Cs).Theseareright
orcorrectresident,rightmedication,rightdose,rightroute,andright
time.
44

Rightroutereferstothewayinwhichthemedicationentersthebody,for
examplebymouth.
Someimprovementsintheadministeringofmedicationincarehomesare
veryeasytoachieve,otherrequirealittlemoreeffortandsomerequireevaluationandchangeof
thesystemsemployedinthecarehome.
7.2. Easytoachieveimprovements
Makesureallresidentshavewater
Residentsusuallyneedwatertotaketheirmedicationandtransportingwateronamedication
trolleyismessy,inconvenientandcanresultinspillage.
46
Itisgoodpracticetoensurethatresidents
areregularlysuppliedwithfreshwatersoasimple,nocostimprovementwouldbetoensurethata
freshwaterroundimmediatelyprecedeseachmedicationround.
AvoidinterruptionsDonotdisturb.
Oneofthecausesofmedicationadministrationerrorsmostcommonlyraisedbystaffandidentified
inanumberofresearchreports
46,47,48,49
isinterruptionofstaffwhiletheyarepreparingand
administeringmedication.Measurestoavoidinterruptionsareeasytoachieveatlittlecost.
Itis,however,importanttomaintaintheatmosphereofapproachabilityofcarehomestaffanda
simpleDoNotDisturbmessagemightgivethewrongimpressiontoresidentsandrelatives.A
brightlycolouredtabardwithsomethinglikePleasedonotdisturbwhileadministeringmedication
mightprovideawordofexplanationforrelativesandresidentswhilewarningotherstaffwho
providethevastmajorityofinterruptions.
Identificationofresidents
Carehomestaffusuallyknowtheirresidentsverywellbutnewandagencystaffmaybeunfamiliar
withresidents.Evenregularstaffmaymisidentifyresidentsfromtimetotime,particularlyones
withsimilarnames.Manymedicationadministrationrecord(MAR)chartsallowthepossibilityof
attachingaphotographoftheresidenttothecharttoaididentificationandthisprocedureshould
beadoptedwheneverpossible.

46
Alldred,Barber,Carpenteretal,2009
47
Dillesetal,2011
48
Thomsonetal,2009
49
Kreckleretal,2008
22

Maintainstocklevelsofasrequiredmedicines
PRN(asrequired)medicationdoesnotformpartoftheregularorderadministerreordercycleand
cannotbepartofamonitoreddosagesystem.ThatmeansthatstocklevelsofPRNmedicationhave
tobewatchedparticularlycarefully.PRNusageandtheamountremainingshouldberecordedon
theresidentsMARchartandcaretakenthatallrelevantinformationistransferredtothenextMAR
chartsothattheamountleft,recentdosageandanyrestrictionsonuse(egmaximumdoseina
giventimeperiod)areknown.AnadequateamountofPRNmedicationshouldbereorderedingood
time.
Correcttimingofmedication
Asrequiredmedicationshouldbeadministeredasrequired,whichmaynotbeatthetimeofthe
regularmedicationround.Timingofcertainregularmedicationsisalsoimportant,forexamplein
thetreatmentorParkinsonsdisease.Staffshouldbemadeawareoftheimportanceofgiving
medicinesatthecorrecttime,evenwhenthisdoesnotmatchthetimeoftheregularmedication
round.
PrintedMARcharts
RoyalPharmaceuticalSocietyguidelines
50
indicatethatmedicineadministrationcharts(MARcharts)
shouldbeclear,indelibleandpermanent.Asanaidtolegibility,carehomeshouldnowexpect
printedMARchartsfromtheircommunitypharmacist.PrintedMARchartsavoidadministration
errorsduetoclericalerrorincorrectlytranscribingthedetailsfromanotherdocumentand
handwritingthatisdifficulttoreadandcanbemisunderstood.PrintedMARchartsshouldbe
reissuedifthereisasignificantchange,forexampleanewprescriptionforanacutemedication
duringthemonthlycycle.
Themorningmedicationround
Morningisthebusiestpartofthecarehomedayandmedicationadministrationerrorsaremore
prevalentinthemorning.Itthereforemakessensethat,withtheagreementoftheprescriber,
medicationsthatdonotneedtobeadministeredinthemorningareadministeredlaterintheday.
Improvingawareness
Trainingsessionstoimprovestaffawarenessofhowtoproperlyhandleandadministermedication
areoftenofferedtocarehomesbycommunitypharmacists.Trainingsessionscanhelpcounteract
someverybasicerrorsthathavebeenobserved
51
suchas:
a. Dispersiblemedicationsmustbeadministeredinwater,notwhole
b. Controlledreleasemedicationshouldbeadministeredwholeandnotsplitor
crushed
c. Incorrectuseofinhalers
d. Theimportantofstrictobservanceoftimingforcertainmedications

50
RoyalPharmaceuticalSocietyofGreatBritain,2009
51
Alldred,Barber,Carpenteretal,2009
23

7.3. Furtherimprovements
Storingmedicationsecurelyintheresidentsownroom
OneofthemedicationadministrationissueshighlightedbytheCHUMS
52
studywasproblems
associatedwiththemedicationtrolleyandthemedicationround.Medicationtrolleysmaybe
difficulttomanoeuvreandiftheycannotbebroughtintocloseproximitytotheresidenthavetobe
madesecurewhilethemedicationisadministered.Itisarguedthatamedicationtrolleyismore
appropriatetoahospitalthanacarehomeenvironment.Theadvantagesofstoringmedicationina
smalllockablecabinetintheresidentsownroomarethatalltheresidentsmedications,including
PRN(asrequired)medication,arekepttogetheranddonothavetobetransportedaroundthecare
home.Medicationcanbetakeninprivacy,themedicationroundmaytakelesstimeandthereis
evidencethatmedicationadministrationerrorsarereduced
53
.Issuestobeaddressedarethat
residentshavetobeintheirownroomsatthetimeofmedicationorthemedicationbroughtto
them,arrangementsstillhavetobemadeforrefrigeratedmedicationandtherehastobean
investmentintimecarefullydistributingmedicationatthetimeitarrivesfromthepharmacist.
MonitoredDosageSystems
MonitoredDosageSystems(MDS)havetheadvantageofsimplifyingthemedicationadministration
processbutthedisadvantageofseparatingmedicationfromitsoriginalpackaging.Althoughnotes
abouttheuseofindividualmedicationsshouldappearontheMARchart,andthemedicationshould
befullyidentifiedontheMDSpacks,itmightbebeneficialtoresidentsandcarehomestaff,inthe
caseofMDSmedication,torequestfromthepharmacistacopyoftheoriginalmedication
informationleaflet(indications,contraindicationsandmethodofadministration)whena
medicationisfirstsuppliedforanindividualresident.
CommunicationwiththeGPpractice
CarehomeresidentsarecommonlyunabletovisittheirGPandrequiretheGPtovisitthecare
home.GPs,ontheotherhand,makeveryfewhomevisitsandaregeareduptoreceivepatientsat
thesurgery,consultingpatientnotesonthesurgeryITsystem.Whereacarehomehasasmall
numberofpreferredGPsitwouldbepossibletoestablishasecureITlinkfromthecarehometo
thesurgeryITsystemsothattheGPcanconsultpatientnotesandupdatethemwhenvisitingthe
carehome.TheITlinkalsomeansthatcomputerbasedprescriptionsmaybegeneratedinthehome
andsignedbytheGPduringavisit.SuchalinkislikelytobringaboutareductioninGPprescribing
andmonitoringerrorsratherthancarehomemedicationadministrationerrors.

52
Alldred,Barber,Carpenteretal,2009
53
PharmaceuticalJournal,2002
7.4. Improvingthesystem

Leaderwithkeyresponsibility
Thereshouldbeanappointedpersonwithinthecarehomewhohasoverallresponsibilityfor
medicationadministrationprocessesandwhocanprovideleadershipandguidancetoothercare
homestaff.Inasmallcarehomethismaybetheregisteredmanageroranassistantbutinalarger
home,whiletheregisteredmanagerretainsoverallresponsibility,thisrolemaybedelegatedtoa
suitablyqualified,responsibleperson.
Reviewbyapharmacist
TheCHUMSstudy
54
recommendedthatcarehomesshouldcommissionanindependentreviewof
theirmedicationprocessesbyanoutsideperson,possiblyapharmacist,whocouldprovidean
overviewoftheeffectiverunningofthewholemedicinessysteminthehome,andoflinkswiththe
associatedGPs,supplyingpharmacistsandthePCT.
Trainingofcarehomestaff
Improvementsinmedicationadministrationsafetythatfollowfromappropriatestafftrainingare
commonsenseandwellproven.
55,56
Apolicyonmedicationtrainingfornewstaffandrefresher
sessionsforexistingstaffneedstobeestablishedinthecarehome.Communitypharmacistswill
oftenprovidetrainingsessionsandcertifiedmedicationtrainingmaybeavailablethroughthelocal
authorityorPCT.
Table4
Relevantevidencebasedguidanceandalertsaboutmedicines
managementandgoodpracticepublishedbyappropriateexpertand
professionalbodies,including:
NationalPatientSafetyAgency
NationalInstituteforHealthandClinicalExcellence
MedicinesandHealthcareproductsRegulatoryAgency
DepartmentofHealth
RoyalPharmaceuticalSocietyofGreatBritain(RPSGB)
SocialCareInstituteforExcellence
Medicalandotherclinicalroyalcolleges,facultiesand
professionalassociations
Thesafeandsecurehandlingofmedicines:ateamapproach(RPSGB,
2005)
Safermanagementofcontrolleddrugs:Guidanceonstrengthened
governancearrangements(DH,2007)
Safermanagementofcontrolleddrugs:Guidanceonstandard
operatingproceduresforcontrolleddrugs(DH,2007)
Thehandlingofmedicinesinsocialcare(RPSGB,2007)
Researchgovernanceframeworkforhealthandsocialcare:Second
edition(DH,2005)
24

54
Alldred,Barber,Carpenteretal,2009
55
Zimmermanetal,2011
56
VandenBemtetal,2009
25

7.5. Informationsourcesforcarehomemanagers
Aswellastheregulations,guides,standardsandcodesofpracticeonmedicationadministrationin
carehomesreferencedinthisdocument,theCareQualityCommission
57
intheir2010guidance
recommendthesourcesshowninTable4tohelpachievecompliancewithOutcome9
Managementofmedicines.

8. CONCLUDINGCOMMENTS
TheCHUMSstudyandmanyotherresearchprojectshavehighlightedthecontinuingproblemofthe
highlevelofmedicationerrorsincarehomes.Notallerrorsareinthehandsofcarehomestaff.
TheremaybeprescribingerrorsattheGPsurgeryorhospitalanddispensingerrorsatthepharmacy.
Carehomemanagersandstaffcanhoweverdosomethingtoimprovetheadministrationand
monitoringofmedicationincarehomesaswellasmaintainingvigilanceforsuspectedprescribingor
dispensingerrorsthatcanbequeriedwiththesurgeryorpharmacy,particularlywhenresidentsfirst
arriveatthecarehomeorreturnfromhospital.
Thecarehomeresidentshouldbeseenasattheheartofthemedicationadministrationprocess,
perhapsasacustomerforwhomaserviceisbeingprovidedbutcertainlyasahumanbeingwhos
dignity,rightsandpreferencesareofparamountimportance.Aswithmanyotheraspectsofcare
homecare,theadministeringofmedicationshouldadoptaresidentcentredapproach.
Itistheresponsibilityofthecarehometoensurethatadequatesystemsformanaging,
administeringandmonitoringmedicationareinplaceandareviewofmedicationsystemsbyan
outsideprofessional,forexampleapharmacist,mayhelptoidentifyanydeficiencies.
Medicationadministrationerrorsarenotintentionalandariseeitherfromasystemsfailureorfrom
alackofawarenessorstressandtirednessonthepartofstaff.Awarenesscanbeimprovedby
appropriatetraining,andstressandtirednesscanbereducedbyappropriatelevelsofstaffingand
organisationinthecarehome.Howeverevenwelltrained,wellrested,staffwilloccasionallymake
mistakes,andmistakeswithmedication,especiallywithfrailolderpeople,canbeparticularly
dangerous.
Theissuesraisedinthisreporthelptohighlightwaysinwhichsystemscanbestrengthenedtohelp
staffavoidmedicationadministrationerrors.Someideassuchasmakingsureallresidentshave
waterbeforethemedicationround,avoidinginterruptionsandaskingforcopiesoforiginal
medicationinformationleafletsarerelativelyeasytoachieve.Others,suchasensuringMARcharts
areprintedandhavephotographsoftheresident,oraskingthatmedicationwhichdoesnothaveto
betakeninthemorningbeprescribedforlaterintheday,maytakealittlemoreefforttosetup.
Trainingtoimprovestaffawarenessisakeyfactortoimprovemedicationsafetyandstoring
medicationsecurelyintheresidentsownroomrecognisesthatthemedicationisthepropertyof
theresidentwhileatthesametimereducingtheriskoferror.

57
CareQualityCommission,2010a
26

Providingasecurecommunicationlinkfromthecarehometothepracticebasedcomputersystem
ofvisitingGPshasclearbenefitsfortheresident,GPandcarehomeandmaynotbeparticularly
difficulttoachieve.
Inthefuturetechnologymaylendahand,withbarcodebasedscanningsystemsalreadyinusein
somecarehomestocorrectlyidentifytheresident,medication,doseandtime.Earlyadoptersofthe
technologywillironoutanyinitialproblemsandeaseofuseandcostwillbethedeterminingfactors
foruptake.
Theprincipleofthe5Rs,rightresident,rightmedication,rightdose,rightrouteandrighttimehas
beenaroundforsometimeandissometimessupplementedbya6
th
R,theresidentsrighttorefuse
medicationwhentheyhavementalcapacity.ThislastRisarecognitionthattheresidentisatthe
heartofthemedicationprocessandthatmedicationadministrationisonbehalfoftheresident.
Whatisstrikingisthattherehasbeenanawarenessofmedicationadministrationproblemsincare
homesforsometimeandmanyofthesolutionssuggestedhavenotchanged.In2004theNational
CareStandardscommissionidentifiedexcellenttrainingonmedicationandtheuseofphotographs
tocorrectlyidentifyresidentsascharacteristicsofgoodperformanceincarehomes.
58

Goodmonitoringandcommunicationbetweeneveryoneinvolvedingettingthecorrectprescribed
drugstothecarehomeresidentisessential.Technologybasedsolutionshavebeenshowntoreduce
medicationadministrationerrors,buttheywillonlybeembracedbycarehomestaffiftheyare
reliable,easytouseanddonotaddsignificantlytostaffworkloadforaparticulartask.
Whateversolutionsareadoptedtoreducemedicationadministrationerrorsincarehomes,the
residentandtheirdignity,rightsandneedsshouldremainparamountwithmedication
administrationbeingonbehalfoftheresidentratherthantotheresident.

58
Daviesetal2004
27

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