Medication errors in Care Homes: What do you have a right to know?

Medication errors in care homes can be avoided with medication training for care homes. This guide highlights what families should know such as what counts as a medication error, types of medication errors and what action to take if something goes wrong.

At a glance

• Medication errors in care homes include missed, incorrect or wrongly administered medicines and can have serious consequences for residents.
• Families should raise concerns immediately, seek medical advice if needed and request a clear written explanation from the care home.
• Residents and relatives are entitled to honest information, access to medication records (with consent) and transparency.

What is a medication error?

 A medicine error is a safety incident.

It involves an error while performing one of these actions:

• prescribing
• preparing
• dispensing
• administering
• monitoring
• providing advice on medicines.

It is not an adverse drug reaction (ADR), which may occur after a drug is administered.

Common types of medication errors

• Wrong medication given.
• Missed doses.
• Incorrect dosage.
• Medication given at the wrong time.
• Incorrect method of administration.
• Failure to record medication properly.

What are the consequences of medication errors?

Medication errors can have serious consequences for care home residents, who are often older, frail, and living with multiple long-term conditions. Even small errors can have serious consequences.    

The impact is usually greater than in the general population because residents have less physiological reserve and take multiple medicines.

Care home residents are especially vulnerable because of polypharmacy (often 7–10+ medicines), cognitive impairment (e.g. dementia), swallowing difficulties, changes in prescriptions during hospital transfers and reliance on others for medication administration.

Medication errors can cause:

1. Physical harm to residents

Medication errors can directly cause injury or illness, including:

• Adverse drug reactions (e.g. bleeding from incorrect anticoagulant doses)
• Overdose or underdose, leading to toxicity or treatment failure
• Falls, confusion, or delirium from sedatives or antipsychotics
• Worsening of existing conditions (e.g. missed insulin → hyperglycaemia)
• Hospital admission or extended illness
• In severe cases, long-term disability or death

Older adults metabolise drugs differently, so even small errors can have big effects.

2. Psychological and emotional harm

Errors don’t just affect the body, they can lead to distress, anxiety, or fear in residents, loss of trust in care staff or the care home, increased confusion or agitation, especially in residents with dementia. feelings of loss of control or dignity.

3. Increased hospitalisation and healthcare use

Medication errors often lead to emergency GP or hospital visits, longer hospital stays, increased risk of hospital-acquired infections and disruption to continuity of care.  Hospital transfers are particularly risky for frail or cognitively impaired residents.

4. Impact on resident’s quality of life and independence

Repeated or serious errors can result in reduced mobility or function, loss of independence, a need for higher levels of care or supervision, an earlier transition to nursing or specialist care.

Why do medication errors happen in care homes?

Understanding why errors happen can help families ask the right questions and identify a safe care environment. 

Medication errors can occur for several reasons, including poor medication systems or human error, such as:

• Staff shortages or high workloads.
• Staff fatigue.
• Poor training or supervision.
• Inadequate record keeping.
• Communication failures between healthcare professionals.
• Complex medication regimes.

Are care homes required to report medication errors?

Yes. Serious medication errors must be recorded and may need to be reported to safeguarding teams or the care regulator in that country.  

For example, care regulators like England’s Care Quality Commission expect care homes to:

• Maintain an open ‘fair blame’ policy.
• Encourage staff to report medicines errors without delay.
• Have a robust process for sharing learning from incidents across the care home group.
• Have mechanisms in place to make changes in practice to improve safety.
• Record accurate details of medicine-related safeguarding incidents. They must record them as soon as possible after the incident. Information must be available for any investigation and reporting.

What are you entitled to know about medication errors?

Families and residents have the right to receive a duty of candour from all registered care homes.

What is Duty of Candour?

Care homes have a duty of candour to be open and transparent with people using their services, such as residents and/or a family member. 

Care homes must:

• Act in an open and transparent way about the care and treatment provided. This includes clear information about prescribed medication.
• Give an honest, accurate explanation of what happened following any error. This must include all the facts, to the best of their knowledge, at the time.
• Tell the care home resident/family member in person as soon as possible after finding out about the incident.
• Offer an apology in person.
• Give access to medication records (with consent).
• Give details of safeguarding or reporting actions taken.
• Tell the care home resident/their family member in person what further enquiries you will need to make.
• Follow this by giving the same information in writing. Give an update on the enquiries.
• Keep a written record of all communication with the relevant person.
• Give information about how they can report their concerns about medicines and medicine-related safety incidents and details of the care home’s complaints process, any local safeguarding processes and relevant regulatory processes.

Can I see my relative’s medication records?

Yes, with consent, families have the right to access medication records and care plans.

What should I do if a care home makes a medication error?

Raise concerns immediately with the care home, seek medical advice if needed and request a written explanation of what happened.

What should I do if I suspect a medication error?

1. Raise concerns immediately

Speak to the care home manager or senior staff member as soon as possible. Ask what medication was given, when and why.

2. Ask for medical advice

If the care home resident appears unwell, request medical assessment from a GP, pharmacist or NHS 111. In an emergency, call 999.

3. Request a written explanation

You are entitled to know:

• What went wrong.
• The impact on the resident.
• What steps are being taken to prevent it happening again.

Care homes have a legal duty ‘duty of candour’ to be open and transparent.

4. Escalate if necessary

If concerns are not addressed, you can:

• Use the care home’s complaints procedure.
• Contact the local authority or NHS commissioning body.
• Report serious concerns to the care home’s care regulator.

How can I check if a care home manages medication safely?

Medication errors in care homes should never be ignored.

Knowing what to do and what you’re entitled to know empowers families to protect their loved ones and hold care providers to account.

What is the impact on care homes of medication errors?

For residents and providers medication errors may be classed as safeguarding incidents.

They can cause potential breaches of duty of care, investigations by regulators, legal claims or complaints from residents or families.

Although centred on residents, errors also affect the care environment by potentially causing reduced confidence among families, staff stress, guilt, or burnout, lower staff morale, increased scrutiny and inspections, reputational damage to the home.

How to reduce the risk of medication errors in a care home

When choosing a care home, look for:

• Robust medication management policies.
• Trained and supervised staff.
• Clear communication with families.
• High quality ratings for safety from care regulators.

You can read verified reviews can also provide insight into how well a home manages medication and resident safety.

You can review safety ratings, inspection reports and family feedback using carehome.co.uk. The website gives access to thousands of care home listings across the UK, care regulator inspection ratings, verified reviews from residents and relatives and expert advice on care quality and safety.

If you’re concerned about medication management or considering alternative care options, you can compare homes and make informed choices on this website.

FAQs