Working with care homes to improve medicines safety

In this blog from Programme Manager, Chris Learoyd, we hear about the work the West of England AHSN Meds team have been doing with care homes to improve medicines safety and reduce medication errors. Here Chris tells us more…

It is no secret that care homes have had a turbulent couple of years in continuing to keep their residents safe throughout the pandemic. The challenges of COVID remain, yet I’ve been inspired by the creativity, hard work and enthusiasm shown by those working in social care to continue to improve the care and ultimately safety of their residents. My work with care homes relates to the Medicines Safety Improvement Programme (MedSIP).

Our approach

The MedSIP works with care homes to test interventions aimed at improving medicines safety in homes, supporting the 7 R’s:

  • Right dose
  • Right medicine
  • Right route
  • Right person
  • Right time
  • Right documentation
  • Right to refuse

The four interventions care homes nationally are implementing to support testing are:

  • Reducing interruptions
  • Safety huddles
  • Learning from events: incidence; errors and excellence
  • Improving 3-way communication between GP, pharmacist and care home

Working with care homes to implement one, or more, of the interventions enables activity to be designed and tailored to the individual home.

Working with care homes

One of the many positives from this programme has been how often – when identifying a challenge in their homes – care home staff  have had ideas and actively wanted to trial solutions, many of which make things intuitively ‘feel’ better. Collecting and recording data around this work allows care home staff to see the impact of their changes.

Naturally, when trialling any new ways of working, some changes make things better quickly (or after a period of time), some changes can make things worse, and some changes can highlight challenges and opportunities we had not seen before.

Vicky, from St George’s Nursing Home, in Worle, tells us how collecting data around the number of interruptions has helped her home identify how to reduce the risk of medication errors.

“I was amazed at the difference in interruption numbers between the different round times. Some of these were avoidable, and some are not or at least less avoidable. For example, the night time round was most frequently interrupted. This was often by residents who become slightly more confused at night, often due to dementia. The data we collected helped us see this, and that the simple changes we tried can make big improvements”.

Vicky’s colleagues have also responded well to this work, she followed on to tell us:

“I’ve noticed a difference in how they’re approaching the person doing the medication round with more thought. The information we’ve shared with them has been really useful to explain the importance of this and the posters act as good reminders.”

Using data and insight

Working with her colleagues to initially count the number of medications per round, Vicky then displayed and shared information in the home about why interrupting a medication round could increase the risk of an error, especially during the ‘safety critical period’ of a medication round.

The “safety critical period” starts when the resident is identified and matched to the MARchart, continues through preparation of the resident’s doses, talking to the resident through administration of the medicines (or observation of self-administration) and ends with the completion of signing of the MARChart.

Once the staff understood that interruptions and distractions during this time can cause increased risk of error, it was evident that sometimes this cannot be avoided and disturbing the medication round is appropriate and important. Some people living in care homes are more prone to deterioration, falls and sudden changes in their condition . In these situations, urgent care, treatment and communication to healthcare clinicians may be required. The person carrying out the medication round may need to provide this urgent care.

Developing an agreed ‘safe and effective’ approach to these interruptions was therefore a priority. Agreeing what interruptions would be ‘appropriate and important’ vs ‘avoidable’ was a first step, albeit not an exact science. The agreed ‘safe and effective’ way of interrupting, may allow the person doing the medication round to pause the round in a safe way, allowing them to return and carry on where they paused.


The early data Vicky and her colleagues have collected is showing promising results. They plan to continue with testing ideas to support their residents in the evening when the medication round is taking place. Sometimes improvement requires lots of people to be involved and is complex; other times small changes by a few people can result in big improvements.

Well done to Vicky and her colleagues for their hard work so far. The work they’re doing is making the care home safer for residents and their teamwork has been very inspiring to see.

Posted on January 27, 2022 by Chris Learoyd, Programme Manager, West of England AHSN

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