What are common medication errors and how can we prevent them?

Frequent errors in adult social care 

• Omissions or late doses (especially time-critical medicines such as Parkinson’s drugs, insulin, some antiepileptics/antibiotics).  

• Wrong dose/medicine/person/route/time and double-dosing. nice.org.uk 

• Inaccurate MARs (missing signatures, unclear reasons for omissions, no record of effect for PRN).  

• Changing formulations (e.g. crushing tablets) without prescriber/pharmacist authorisation.  

• Poor PRN practice (no protocol; given routinely; max dose exceeded).  

• Controlled drug (CD) handling errors (storage, register balances, witnessing).  

• Storage/temperature issues that reduce effectiveness.  

• Weak escalation/reporting, so services don’t learn from incidents.  

What “good” looks like (prevention at a glance) 

• Clear roles & policies. Follow NICE SC1 (care homes) and NICE NG67 (community). Define when staff assist vs administer, and who can make clinical decisions.  

• MAR accuracy every time. Check right person/medicine/dose/route/time and record immediately (including refusals/omissions with reasons). CQC expects secure, accurate, up-to-date MARs.  

• Time-critical lists. Identify residents with time-critical medicines and plan around the prescribed times (not just round times). Record actual time given and actions for delays. Use NHS SPS resources to brief the team.  

• PRN protocols. For each PRN, document indication, dose/max/interval, when to offer/not offer, non-drug alternatives, and record effect after administration. Review patterns regularly.  

• No covert/admin changes without approval. Only alter formulations or give covertly after capacity assessment, best-interests decision, and prescriber/pharmacist agreement, document and review.  

• Secure storage & temperatures. Lockable storage; CD cupboards/registers where required; medicine fridges 2–8 °C and ambient stores typically ≤25 °C with daily logs and action if out of range.  

• Competence & refreshers. Ensure staff are trained, assessed as competent, and have regular reviews per CQC expectations (medicines optimisation).  

• Report, review, learn. Have a robust process to identify, report, investigate and learn from errors/near misses (linking to Reg 12). Use CQC’s guidance on reporting medicine-related incidents; treat serious delays/omissions as safety incidents.  

Key links 

• NICE SC1 (care homes) & NICE NG67 (community). nice.org.uk 

• CQC – MAR records; reporting medicine-related incidents; CDs in care homes. cqc.org.uk+2cqc.org.uk

• NHS SPS – Time-critical medicines resources. SPS – Specialist Pharmacy Service 

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