Care organisations work hard to provide an excellent standard of care to the people they support. Part of this includes supporting people with their medicines.

Reducing medicines errors is a goal of almost every care organisation but it can be hard to know where changes need to be made, or even where to start!

To help Managers and senior staff navigate their way through this area of medicines management, we have prepared a suite of helpful documents and resources. Executive members  can download all 6 information sheets (and linked practical advice documents) from the series to form a complete pack of advice and support on how to reduce and handle medicines errors in your service(s).

Our ‘Reducing Medicines Errors’ Series provides information to help Managers:

  • Identify the causes of medicines errors;
  • Implement actions to prevent errors arising;
  • Audit errors that occur within your organisation; and
  • Make plans for the future.

Why Do Medicines Errors Occur?

Medicines errors often occur due to one, or sometimes a combination, of four different factors. These are:

  1. Team
  2. Procedures
  3. Personal
  4. Work Environment

To understand better about why medicines errors are likely to happen, and how to reduce this likelihood, we will be looking more closely at each of these factors.

  1. Team

It is important when administering medicines that you have the right skill mix within your team. Where people lack the appropriate skill set, it can lead to confusion and mistakes.

Our ‘TEAM’ downloadable information sheet:

  • Explains what the ISSUE is
  • Gives EXAMPLES of when the issue occurs
  • Provides tips for PREVENTION of the issue arising

The download also contains Training Overview Checklists for both support staff and Managers.

  1. Procedures

The second reason why medicines errors might occur within an organisation, is where the medicines administration procedures aren’t working as they should or being followed as they should.

We have developed a Medication Policy Self-Assessment Tool for you to complete to see whether your policy and procedures could need updating to help reduce medicines errors where you work. We have also created an information sheet discussing the importance of a clear and easy-to-read medicines policy and procedures in the context of reducing medicines errors.

  1. Personal

The third reason why medicines errors might occur within an organisation, is where staff members have personal circumstances or issues that affect their ability to safely administer medicines.

Alongside our information sheet, we have also developed a Discussion Sheet for you and your senior team to review to determine whether appropriate consideration is being given to supporting your staff with their personal issues, in order to help reduce medicines errors.

  1. Work Environment

The fourth reason why medicines errors might occur within an organisation, is where the work environment staff are administering medicines in, increases the likelihood of errors occurring.

Completing our Risk Assessment will help you determine whether your work environment is providing the optimum conditions for safe administration of medicines.

The Role of Managers & Senior Staff in Reducing Medicines Errors

Managers and Senior Staff are crucial when trying to reduce medicines errors in an organisation.

Not only do they have to help identify the errors, but they also need to know how to manage them, learn from them and prevent them reoccurring.

We have set out the role of Managers & Senior Staff in reducing medicines errors including:

  • how to become AWARE of medicines errors that occur
  • how to ASSESS medicines errors to determine the causal factors
  • how to ADDRESS the errors to ensure they don’t happen again

We have included a case study and example action plan to help Managers & Senior Staff understand the process that should be followed once an error is discovered to prevent a similar error occurring again.

Training Pathways to Help Reduce Medicines Errors

As part of this series, we also look into how implementing clear and complete training pathways can make a huge difference in reducing the likelihood of medicines errors occurring.

We discuss the use of Training Pathways in organisations including:

  • WHAT is a Training Pathway?
  • WHO should be following a Training Pathway?
  • WHY have Training Pathways?
  • HOW will Training Pathways help reduce medicines errors?

We have also prepared template Training Pathways for both staff and Managers/ Senior Staff for you to download and implement in your organisation.


In summary, there are numerous factors that can affect the likelihood of medicines errors within a care organisation.

There are also clear and simple ways that Managers can identify why medicines errors are occurring and make positive change within an organisation, both to it’s culture, and it’s practices, to help prevent errors occurring.

We hope that these downloadable resources and tools will provide organisations with the support system they need to improve outcomes both for their staff, and the people they so carefully support.

NB these are only available to BCA Executive members. Should you like to have more information about becoming a BCA Executive member please see the details on the front page or contact Sue Dorling:, 

If you’d like to speak to one of our experienced Pharmacist team about particular issues or incidents in your organisation – contact us anytime on, or call 0333 939 0053. Remember, there’s no issue we haven’t seen!