Dealing with mistakes

Occasionally a mistake may be made with a person's medicines (for example, 1 tablet is given rather than 2). If this happens, staff in the care home should ask for advice from a health professional about what they should do to make sure the person is safe. Who they contact will depend on whether the mistake happens during the working day or out of hours. It may be a health professional who prescribed the medicine, one who works in an out-of-hours service, a local pharmacist or one who works in an emergency service.

Care homes should record any mistakes or suspected mistakes. If the mistake has or might have put the resident at risk (a safeguarding issue), care homes should report what has happened. Not all mistakes are safeguarding issues.

Adult care homes in England should report any concerns about medicines which are considered a safeguarding issue to the Care Quality Commission.

Safeguarding for adults is:

Ensuring that people live free from harm, abuse and neglect and, in doing so, protecting their health, wellbeing and human rights.

(Care Quality Commission 2010)

Children's homes should also report all safeguarding issues.

Safeguarding for children is:

  • protecting children from maltreatment

  • preventing impairment of children's health or development

  • ensuring children are growing up in circumstances consistent with the provision of safe and effective care

  • taking action to enable all children to have the best outcomes.

(Department for Education 2013)

When there is a mistake with a person's medicines, care home staff should find out the cause. They should be trained and have the skills to do this.

People who live in care homes, and their family members or carers, should know who to speak to if they have any worries about medicines. Staff in the care home should give residents, and their families or carers, information about the care home's complaints process, and other processes that they can follow, such as those of the local authority and the Care Quality Commission. All people who live in care homes should be able to have someone to help put their views across (called an advocate) and should know how to contact an independent complaints service.