There’s a gap in a client’s MAR chart. What should you do?

What is a medication error?

In home care, a medication error is when a client doesn’t get the correct medication. A mistake may occur while administering medication, supporting a client to take their medication, or recording the details on a medication administration record.

Medication errors aren’t always down to the care worker. A client might be responsible for their own medication and have made a mistake, or the pharmacist may have supplied the client with the wrong drugs.

Not all medication errors are immediately harmful, but, depending on the situation, some can be dangerous or even fatal.

Why are MAR chart errors dangerous?

The MAR chart should be a record of medication administration – after all, MAR stands for medication administration record. However, if there are gaps or obvious errors in the chart, you can’t trust it.

You should never make assumptions about a client’s medication. But, once you’ve discovered a gap in a MAR chart, you can’t be certain what has happened.

Both of these options can have dangerous consequences, depending on the drugs involved.

Why are there gaps in a client’s MAR chart?

If you see a gap in a MAR chart, it might be because the client missed a dose of medication. But it might also simply mean that a care worker didn’t record that the medication was administered. Unfortunately, it’s hard to tell which is the case.

Both missed medication and missed recording can be dangerous – and regulators will take these errors very seriously.

CQC inspectors want to see complete medication records, without gaps. If there are issues with your record-keeping, the CQC will treat this as a serious compliance failure.

What CQC inspectors ask to see, and how to have it ready

Frequent medication errors and missing records can indicate poor leadership – it can be a sign that management teams aren’t holding regular audits and spotting problems. It also suggests that care workers aren’t given proper medication administration training, or that they’re too rushed to complete paperwork during a care visit.

Whatever the reason, MAR chart gaps and errors reflect badly on your care service – so you need to fix the issue, and quickly.

What should I do when I discover a medication error?

Your first priority is your client’s safety. Next, you’ll need to find out exactly what happened, document the incident, report the error, and hold an internal investigation.

How can we improve our medication safety?

There are two main aspects of improving medication safety: avoiding errors, and spotting errors quickly so that you can take action. To avoid errors, make sure your team are well-trained and look for patterns in previous errors. To spot them quickly, audit your medication records regularly – and your home care software should alert you to delayed or missed medication.

Train your team

Medication administration training should already be included in your mandatory training schedule. However, if you’re seeing regular errors, this is probably a sign that your training isn’t enough.

If you use electronic medication administration records (eMAR), make sure your team are fully trained on those too, as well as any care planning software. Your team should also understand what to do if they discover a medication error or recording gap.

Look for patterns

When you look at recent medication or reporting errors in your care service, do they have anything in common? Is it the same carer who often leaves gaps, or do errors often occur at the same time of day? Are support workers skipping paperwork because they’re rushing to their next visit, or at the end of their shift?

You might be able to make some changes to your service’s rostering, training programme, or policies and procedures to reduce the risk of errors in future.

Audit at three levels

If you review your files every month, six months, or once a year, gaps and errors can build up – and it might take a long time to realise there’s a problem. Get every team member involved instead:

Let software catch what people miss

PASS shows you the medication picture in real time on your tablet or smartphone. There’s no need to wait until you’re in the client’s home or auditing paper MAR charts at the end of the week. PASS also prompts carers to administer the correct medication at the appropriate time.

Every medication task listed for the visit in the PASS app, with allergies and risks up front – and each dose timestamped as it’s recorded

Here’s how that compares to a paper MAR chart:

The team at PASS will even provide training for your care workers, so they’re confident using the software. Combined with good medication administration training and regular comprehensive audits, PASS eMAR helps improve medication safety across your care service.