Medication administration errors are common in the care home setting, exposing residents to risk of harm as well as adding additional challenges for care home staff and managers. The South West Patient Safety Collaborative (PSC) facilitated quality improvement pilots in local care homes to improve the safety of medicine administration.


As I became involved with the pilot, I became very aware that [managing interruptions] could have a major positive impact upon our service. I was able to engage my staff team enthusiastically as it didn’t add pressure to their roles, and they could see the positive development within the service.


Trevor Jackson, Deputy Manager, Langley House, Somerset

What the project involved

The South West PSC worked to improve the safety of medicine administration in care homes in South West England by carrying out tests of change in a range of areas including managing interruptions, three-way communication, safety huddles, and learning from events, incidents and errors.

This case study focuses on Langley House, a care home in Somerset providing specialist care for 11 residents with complex needs.

What we did before the pilot

  • Recorded the interruptions during the twice daily medicines rounds for one week
  • Nominated Medicine Safety Champions to share their knowledge and professionalism with staff
  • Champions went through examples of consequences and scenarios with staff
  • Communicated key messages and the importance of behaviour change to all staff
  • Assessing of all staff to a competent level to enable them to give medications
  • Informed staff to direct any questions to other members of the staff team as, between them, they should be able to answer.

Actions during the medicines round

  • New red aprons were worn by staff on medicine rounds
  • Interruptions during the medicine rounds were recorded for one week
  • Staff were reminded not to direct questions to the staff on the medicines round.


Over one week, the total number of interruptions during medicines rounds reduced from 45 to 13.

Staff questions went down from 22 to only 6.

A safety attitude survey completed by staff before and after the pilot showed staff felt disagreements post-pilot were resolved more appropriately and their input was well-received.

Next steps

This was a pilot study forming part of the National Patient safety Improvement Programme’s workstreams on deterioration and medicines safety.

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