Case study 3. Improving the safe use of medicines for residents in care homes
Submitting InstitutionUniversity of Leeds
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypePolitical
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Leeds researchers first proposed and tested the concept of a
pharmacist-led clinical medication review and showed its effectiveness in
care homes. This led to a collaborative study on medicines' safety in care
homes which showed seven out of ten residents, on any one day, had at
least one medication error. As a direct result, there was a
ministerial-led summit, and the Department of Health (DH) issued a `Health
Alert' requiring NHS trusts to take immediate action, citing the study
findings. This was followed by several national initiatives to take
forward the recommendations of the study, including a DH commissioned
initiative involving Royal Colleges, the National Care Forum, the Health
Foundation and Age UK. Prototype tools developed on the basis of our
research and with Leeds input were reported in 2012 and are now being
evaluated for national roll out.
Researchers at Leeds (including David Alldred, Research Clinical
Pharmacist 2002 - 2005, Lecturer in Pharmacy 2005-2013; David Raynor,
Senior Lecturer 1996-2001, Professor of Pharmacy Practice 2001- present)
first proposed and tested the concept of `clinical medication review' by
pharmacists of people living in their own homes. This research showed that
the approach could reduce the number and cost of medicines without adverse
effects such as increased use of services. This model was subsequently
successfully tested in the care home setting where frail older patients
are commonly prescribed multiple medicines with an increased risk of
adverse drug events. The study of 661 patients in 65 care homes in Leeds
confirmed that the prescribing of medicines in this setting was
sub-optimal, leading to a loss of potential benefit and an increased risk
of harm .
In 2005 we responded to a Department of Health (DH) call for research
into improving safe use of medicines in care homes and formed a
collaboration with colleagues at the University of London School of
Pharmacy (led by Nick Barber) and the University of Surrey (led by Peter
Buckle) to carry out the Care Homes' Use of Medicines Study
(CHUMS). With a £500,000 grant from the National Patient Safety Research
Programme, we combined Leeds research expertise in medicines use in care
homes (Raynor and Alldred) with medicine error research
from London and ergonomics expertise from Surrey.
Alldred was the Project Co-ordinator for the three sites in the
study, which comprised 55 care homes in West Yorkshire, Cambridgeshire and
South London. Researchers undertook clinical medication reviews,
scrutinised GP and care home records, visited pharmacies, observed
medication administration in the homes and conducted 89 interviews. The
analysis showed seven out of ten patients experienced at least one
medication error. Errors occurred throughout the system, from prescribing
to dispensing to medicines administration. Each stage had an 8-10% chance
of being performed incorrectly. The research showed that factors
contributing to errors included doctors who were not accessible, did not
know the residents and lacked information in homes when prescribing; staff
workload, lack of medicines training and drug round interruptions; lack of
team work among care and health professionals; inefficient ordering
systems; inaccurate medicine records and reliance on verbal communication
We made a number of suggestions to reduce the risk of medicines errors,
including that each home have a lead GP to co-ordinate prescribing and
monitoring of medicines; that clinical pharmacists regularly review
residents to identify and rectify errors; and that pharmacies and homes
should review how they order and dispense medicines. We also recommended
that within Primary Care Trusts in England, the Chief Pharmacist should
take responsibility for ensuring safe systems.
As part of the CHUMS study we also published:
— A tool we developed and validated to identify monitoring errors in care
home residents ;
— Detailed analysis showing a lack of recording and sharing of drug
sensitivity information ;
— Research on problems associated with the administration of non-oral
dose forms, notably inhalers .
References to the research
1. Zermansky AG, Alldred DP, Petty D et al. (2006). Clinical
medication review by a pharmacist of elderly people living in care homes
-randomised controlled trial. Age and Ageing, 35:586-91.
First published paper demonstrating the now common use of `clinical
medication review' for care home residents.
Peer reviewed report to the Department of Health Patient Safety
Research Programme; from which the DH drew the evidence to develop
3. Barber ND, Alldred DP, Raynor DK, Dickinson R et al. (2009).
Care homes' use of medicines study: prevalence, causes and potential harm
of medication errors in care homes for older people. Quality and
Safety in Health Care, 18:341-346.
Publication of the main findings of the CHUMS study.
4. Alldred DP, Zermansky AG, Raynor DK et al. (2008). Development
and validation of criteria to identify medication-monitoring errors in
care home residents. International Journal of Pharmacy Practice, 16:317-323.
Publication of the novel tool developed in the CHUMS study for
identifying medication errors in care homes.
5. Alldred DP, Standage C, Zermansky AG, Barber ND, Raynor
DK, Petty DR. (2010). The recording of drug sensitivities for older
people living in care homes. British Journal of Clinical Pharmacology,
69:553-557. DOI: 10.1111/j.1365-2125.2010.03631.x
Detailed analysis of one of the main areas of concern identified in
the CHUMS study — recording of drug sensitivities (allergies).
6. Alldred DP, Standage C, Fletcher O, Savage I, Carpenter J,
Barber N, Raynor DK. (2011). The influence of formulation and
medicine delivery system on medication administration errors in care homes
for older people. BMJ Quality and Safety, 20:397-401. DOI:
Findings from the CHUMS study relating to another key area of concern
— formulation (type of medicine e.g. tablet, liquid, inhaler) and
medicine delivery system.
Note: All Leeds researchers in bold. Publications available on
request from the HEI.
Details of the impact
There are more than 370,000 older people living in around 10,000 care
homes in England, many of whom are frail, vulnerable and have multiple
medical conditions. Work at Leeds introducing the concept of clinical
medication review in care homes, led to collaboration with teams in London
and Surrey to carry out the DH-commissioned CHUMS study. We showed that
for 70% of care home residents, who were taking on average eight medicines
each, there was one or more error(s) in prescription, monitoring,
dispensing or administration . It was clear from the research that
errors were found in all parts of the process and there was a lack of team
work from the health and care professionals involved. The publication of
the report led to a ministerial summit to discuss the findings and develop
a way forward [A].
In January 2010, the Chief Pharmaceutical Officer and the Director
General of Social Care jointly wrote to all Directors of Adult Social
Services and PCT Chief Pharmacists drawing attention to CHUMS as "an
important research study" which "strongly indicates there is
considerable scope for improvement" in how medicines are used in
care homes. At the same time an `immediate action' DH Alert was issued
citing the findings of CHUMS and requiring PCTs to work with care home
staff, general practitioners and pharmacists to determine how medication
errors in care homes can be reduced, with a four-month deadline [B]. This
led to changes in practice across the country [A] including the
commissioning of new services in NHS Bradford and Airedale, NHS
Buckinghamshire and Oxfordshire, and NHS Surrey. Most notable was the
introduction of a pharmacist-led medicines review for care home residents
[A] to ensure they were safe and effective, as we had recommended on the
basis of our research.
Press releases designed to get the findings to the public led to the
research and subsequent recommendations by the DH receiving considerable
national media attention. Raynor and Alldred were
interviewed live on BBC News 24, Radio 5 Live, and more than 10 local
radio stations. There were prominent reports of the study findings in the
national (Times, Daily Telegraph, Guardian and Independent) and local
press. One of the key points we made was that anyone concerned about a
relative in a care home should ask for a medicines review.
In April 2010, the Care Quality Commission (CQC) approached Alldred
and Raynor to review new assessment tools, developed on the basis
of CHUMS findings, for the management of medicines in care homes [C]. The
tools were subsequently used within a wider review of the quality of
healthcare provision in care homes published in March 2012 [D], along with
a report from the British Geriatrics Society showing a lack of access to
NHS services for care home residents [E].
Also in response to CHUMS, the Health Foundation and Age UK hosted three
focus groups for the Age UK network `Experts by experience'. This
was the start of a nine-month improvement project to improve the safety of
care for those living in care homes [F],[G].
A series of six workshops to allow participants to act on the CHUMS study
were held in Spring 2010 across England, with speakers including the
National Clinical Director for Primary Care, the National Clinical Lead
for Quality and Productivity, the Chief Pharmacist at the DH. The Centre
for Pharmacy Postgraduate Education developed a learning programme based
on the CHUMS study and this has been delivered to 2500 pharmacy staff
across England [H].
In 2010, The Safety of Medicines in Care Homes Project was
launched, bringing together the Royal Colleges of Psychiatrists,
Physicians, General Practitioners, Nursing, and the Royal Pharmaceutical
Society, representatives from the Care Home Sector, Age UK and the Health
Foundation to take forward the recommendations from the CHUMS report [G].
Alldred is a member of the Reference Group for this project, which
has developed a suite of tools, on the basis of CHUMS findings, to improve
medication safety in this setting. From summer 2012 these prototype tools
were evaluated in 82 care homes, prior to national dissemination and
implementation [I]. They include:
— A summary medication record (held by the resident): 54% of care homes
that tested the record wished to use it in the future;
— Learners' workbook (to provide basic training in safe use of
medicines): 70% wished to use the workbook in the future;
— Leadership guidance (to support managers in safe use of medicines): 84%
wished to use in the future;
— Framework for making the best use of medicines across all settings: 80%
found that the framework successfully clarified areas of responsibility in
In 2012 the Royal Pharmaceutical Society Scotland published their report
Improving pharmaceutical care in care homes. Of eight sources of
evidence cited, two were from the CHUMS study and, of 16 recommendations
four were based on the results of the CHUMS findings [J], [A].
Also in 2012, a DH commissioned report on improving the use of medicines
for better outcomes, described CHUMS as a major study which formed a "strong
call to action to improve the use and safety of medicines in care homes"
[K], [A]. It stated its intentions to integrate recommendations from The
Safety of Medicines in Care Homes Project upon completion.
Sources to corroborate the impact
A. Individual corroboration: Chief Pharmaceutical Officer, Department of
B. DH Alert (2010) 001: The use of medicines in care homes for older
C. Individual corroboration: Chief Pharmacist, Care Quality Commission
D. Care Quality Commission (2012). Meeting the health care needs of
people in care homes
E. British Geriatrics Society (2012) Failing the Frail: A Chaotic
Approach to Commissioning Healthcare Services for Care Homes. http://www.bgs.org.uk/index.php?option=com_content&view=article&id=1907:cqc-report-
F. Health Foundation. Making care safer: Care Homes Use of Medicines
G. Individual corroboration: Chair, Partnership Project Group, Department
of Health; National Care Forum
H. Individual corroboration: Director, Centre for Pharmacy Postgraduate
I. Department of Health, Royal Colleges, National Care Forum, The Health
Foundation (2012). An integrated approach to medication safety in care
J. Royal Pharmaceutical Society Scotland (2012). Improving pharmaceutical
care in care homes. http://www.rpharms.com/promoting-pharmacy-
K. Department of Health, 2012. Improving the use of medicines for better
outcomes and reduced waste; an Action Plan.