Underlying causes of errors
Giving incorrect doses of medicines was the most commonly reported error that the CQC found from statutory notifications. Common causes of these errors were traced back to team members not checking MAR charts properly, or at all, before giving medications.
Missed medicines in care homes were often caused by changes in timings of medication rounds, while in domiciliary and community care late arrivals to visits by carers often caused medicines to be missed or given late.
This highlights the need to ensure constant MAR chart compliance, and for adequate staffing in care homes, and for adequate time for visits and travel between visits in home care.
Staffing and time for and between visits is an especially difficult challenge in state funded care, where having visits of an adequate length commissioned by local authorities, and recruiting enough staff with the scarce resources available is a constant struggle.
Poor records – is the CQC nudging providers towards eMAR?
The CQC has in recent months become more of an advocate for using more software in the care sector, a message they were previously quite wary to transmit.
In the new CQC guide the CQC do point out that:
“The key contributing factor for administration errors was poor record keeping. We saw that MARs were either not completed, or not completed accurately. Discontinued medicines and incorrect strengths of medicines were sometimes found on MAR charts.
"These types of errors were more likely when MAR charts were hand-written or included additional hand-written medicines. Where MARs were hand-written in care homes, they had not always been second checked to ensure they were accurate.”
CQC inspections – how eMAR helps:
Making sure that MAR chart compliance is enforced and that any changes to medications are made properly, and across all records, is one area where electronic MAR and electronic medicine management has made a hugely positive impact.
Here are a few extracts directly from a CQC inspection report of The Bay Care Group, a mid-sized (but fast growing) home care provider in Devon, rated Outstanding by the CQC last May:
“People were supported safely with their medicines and told us they were happy with the support they received. Staff completed electronic medication administration sheets (eMAR). The computer system alerted staff if all parts of the eMAR had not been completed before the care staff left a visit. This reduced the risk of missed medicines.”
“The electronic medication administration sheets (MARs) were updated in real time. This meant changes to people's medicines could be updated quickly. When people were prescribed a short course of antibiotics, the system would work out the end date and take the medicine off automatically.”
Access software enables providers of all shapes and sizes to make the move from paper or Excel based systems to fully developed medication management software, whether you operate care homes, home care, supported living or other services.
Read a factsheet on eMAR and medication management in residential care
PRN medicines
Alongside poor record keeping in regard to PRN medications, the CQC also discovered that many errors came about where staff had a lack of training.
For PRN medicines to help with mental health needs or challenging behaviour, the CQC found that staff were not keeping proper records on the exact reasons why those medicines were given in each instance, or any steps they took first to try and deescalate challenging behaviour with resorting to medicines.
Good practice of PRN use highlighted in the report included Dimensions in East Anglia using guidance around psychotropic drugs that encouraged staff to try other techniques to reduce anxiety and mental distress which had resulted in some people being taken off those medicines altogether.
Dimensions had also been working within the STOMP (Stop Over-Medication Of People with learning disabilities) NHS initiative to shape this approach.
Regular training is vital
NICE recommends that care staff should have an annual review of their skills and competency. The CQC’s research found that some providers were not carrying out these regular competency checks and assessments.
The CQC found that on several occasions, medication incidents could be linked back to little or no training and competency reviews for staff.
Running safely and improving
Another area of particular importance was having a proper medications policy in place, in line with the latest guidelines and best practice, which are readily available online from NICE and other sources.
Sticking to policies was another issue, for example where staff did not follow care plans, signed MAR charts before giving medicines, or signing off MARs where they had not given the medicines themselves.
There was also a clear lack of proper audits and monitoring systems in some providers. This meant both that missed errors could not be spotted, patterns could not be detected (for example in polypharmacy or side effects linked to incidents) and improvements could not be made to services.
This is another way that progressing to electronic medication records helps. It makes audits much, much faster and makes proper analysis possible.
Compare auditing stacks of paper MAR charts and then trying to identify the key issues and correlations, on both an individual and organisational level, to utilising computational power to do all this for you and give you the information, which you can then use to make incremental improvements, in training, to a specific service user’s medicines or in medication practice across your service.
Download the full report, with the sections relating to social care on pages 36 to 42.