Medication Errors — What to Do
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. How you respond to an error is critical — the resident's safety comes first, followed by honest reporting and learning.
Understanding Medication Errors
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. This includes wrong drug, wrong dose, wrong route, wrong time, wrong patient, omission of a dose, or extra dose given. All medication errors must be reported, investigated, and learned from. A just culture approach should be taken — staff should feel safe to report errors without fear of unfair blame.
Immediate Steps — Follow This Sequence
- 1Stay calm and assess the resident — check for any signs of adverse reaction or distress
- 2Do not leave the resident unattended if they are showing any concerning symptoms
- 3If the resident is in immediate danger (e.g. severe reaction, loss of consciousness), call 999
- 4If the error is identified quickly and the resident appears well, contact the GP, NHS 111, or the on-call pharmacist for advice
- 5Do not attempt to 'correct' the error yourself (e.g. giving an extra dose to make up for a missed one) without professional advice
- 6Record exactly what happened: what medication, what dose, what route, what time, who was involved, and what the error was
- 7Record the resident's condition and any symptoms observed
- 8Inform the nurse in charge or manager immediately
- 9Complete an incident report form
- 10Notify the resident's next of kin if appropriate, as per organisational policy
Common Medication Errors
Wrong medication given
Wrong dose given
Dose omitted
Wrong time
Crushed or modified inappropriately
Duplicate dose given
Reporting & Learning
- 1.All medication errors must be recorded as an incident and reported through the organisation's incident reporting system
- 2.CQC Regulation 12 requires providers to have systems to assess, monitor, and mitigate risks to safety — medication error reporting is part of this
- 3.Significant medication errors should be reported to CQC as a statutory notification (under Regulation 18, which requires notification of any event that adversely affects a person's welfare)
- 4.Near-misses should also be reported — they are learning opportunities that can prevent future harm
- 5.Root cause analysis should be conducted for significant errors to identify system failures, not just individual mistakes
- 6.Learning from errors should be shared with all staff through team meetings, supervision, and training
- 7.Repeat errors or patterns should trigger a review of the medication management system
- 8.National Reporting and Learning System (NRLS) and/or local Clinical Commissioning Group (CCG) reporting requirements should be followed
A Just Culture Approach
A “just culture” is one where staff feel safe to report errors and near-misses without fear of unfair blame or punishment. The CQC and NICE both support a just culture approach. In a just culture:
- • Human error (an honest mistake) is met with support and learning
- • At-risk behaviour (taking shortcuts) is met with coaching and system improvement
- • Reckless behaviour (conscious disregard for safety) is met with disciplinary action
The vast majority of medication errors are caused by system failures — not individual incompetence. Blaming individuals without fixing the system does not prevent future errors.
Emergency Contacts for Medication Errors
If the resident has a severe reaction, loss of consciousness, or difficulty breathing
NHS 111 for advice on medication errors when the resident appears stable
For advice on whether a missed dose should be given late, or potential interactions