Return to interactive Impact Report

Case study

Medicines Safety Improvement Programme (MedSIP)

The aim of the programme was to reduce medicine administration errors in care homes by 50% by March 2024, through medicines optimisation and quality improvement.

A Managing Interruptions intervention was tested in one care home.

A 3-way Communication Intervention was tested in two care homes.

Managing Interruptions to the Medication Administration Round

Evidence suggests that interruptions are frequent during the medicine administration process and have been found to be associated with an increase in occurrence and severity of administration errors.

Following review of baseline interruption data gathered from medication administration rounds, one care home identified a main ‘change idea’ to test aimed to reduce the number of interruptions. This involved a change in their processes when giving residents their medication, allowing one carer to administer medication while a second carer managed the cause of interruptions.

After the change idea was implemented the care home saw a 43% overall reduction in interruptions to the member of staff undertaking the medication administration round. There was also a 25% overall reduction in time it took to undertake the rounds.

The following benefits were reported by staff:

  • It made the administration round safer
  • It released staff time, in turn, giving them more time to care for the residents
  • Empowered staff to politely challenge other staff when they were interrupted.

3-Way Communication Intervention (between the GP Practice, Community Pharmacy and Care Home)

Two care homes in the programme identified communication problems with their medication ordering processes between the GP practice and community pharmacy and contacted them regularly to follow up resident medication orders. They felt this impacted on resident safety and timely receipt of medicines and wanted to identify improvements to the communication pathways.

Baseline data was collected and included details of the number of contacts made with the GP practice and community pharmacy regarding residents’ medicines along with details of how quickly issues were resolved. On review of this the care homes identified a main ‘change idea’. This was to undertake a 3-way communication meeting with GP practice, community pharmacy and care home to discuss communication and resolve any communication process issues.

After the change idea was implemented, the following results were achieved in the homes:

  • % of issues resolved in 24 hours increased from 31% to 100% with the community pharmacy in one home
  • % of issues resolved in 24 hours increased from 0% to 81% with the community pharmacy and from 4% to 56% for the GP practice in another home.

Return to interactive Impact Report