Root Cause Analysis for Medication Errors: From Incident Review to System Redesign

February 2, 2026

Medication incidents are among the most scrutinised events in adult social care because they combine immediate risk with clear accountability expectations. Yet many providers still investigate medication errors as isolated staff mistakes rather than system failures created by workload, unclear processes and weak controls. Applying root cause analysis through recognised quality standards and frameworks helps providers identify why errors were possible, how controls failed and what redesign is needed to prevent recurrence.

This article sets out how to use RCA for medication errors in a way that strengthens safety, governance assurance and commissioner confidence.

Why Medication RCA Must Go Beyond “Human Error”

It is tempting to conclude that medication errors occur because someone was distracted or failed to follow procedure. In reality, staff errors usually sit within wider contributory factors such as rushed handovers, unclear responsibilities, poorly designed MAR charts, stock management problems or inconsistent competency checking.

Medication RCA should therefore test:

Whether the medication pathway is clear end-to-end (ordering, storage, administration, recording, disposal)
Whether staff competency is verified and refreshed (not assumed)
Whether workload and environment enable safe practice
Whether audits detect risk early and drive improvement

Operational Example 1: Wrong Dose Due to Time Pressure and Poor Layout

Context: A staff member administered the wrong dose of a prescribed medicine during a busy evening round.

Support approach: RCA examined rota pressure, shift handover information, MAR chart layout, storage arrangements and supervision records.

Day-to-day delivery detail: The medication trolley was stocked inconsistently, requiring staff to search for items. The MAR chart had multiple dose strengths recorded on one page, increasing selection risk. The round coincided with a challenging behaviour incident, pulling staff away mid-process. The staff member returned and resumed without a clear re-check step.

How effectiveness or change is evidenced: The provider redesigned trolley organisation, separated medicines by strength, and introduced a “pause and re-check” step whenever administration is interrupted. Evidence included fewer near-misses, improved audit scores, and supervision notes confirming staff adherence to interruption controls.

Using RCA to Strengthen Medication Controls

Medication RCAs are most valuable when they lead to control improvement. Typical control changes include:

Clearer role allocation (who administers, who checks, who signs)
Environmental controls (quiet zones, reduced interruptions, protected time)
Competency verification (observations, annual refresh, targeted checks after incidents)
Audit redesign (spot checks aligned to known error risks, not generic tick-box review)

Operational Example 2: Missed Medication Due to Shift Handover Failure

Context: A prescribed medicine was not administered on time because the incoming shift was unaware of a medication change.

Support approach: RCA reviewed handover formats, communication with pharmacy/GP, incident timeline, and management oversight.

Day-to-day delivery detail: The medicine was delivered after the morning handover. The outgoing shift assumed the incoming shift would see the delivery note. The MAR chart update was delayed until later. The next round proceeded using the previous MAR version, leading to omission. There was no formal “medication change notification” trigger.

How effectiveness or change is evidenced: The provider introduced a medication change log reviewed at each handover, requiring staff to confirm recent updates and highlight time-critical medicines. Evidence included improved documentation of changes, fewer omissions, and stronger assurance reporting to governance meetings.

Commissioner Expectation

Commissioner expectation: Commissioners expect providers to evidence a robust medication safety system, with clear learning from incidents and measurable improvement. They will look for assurance that medication errors lead to control strengthening, competency review and reduced recurrence.

Regulator / Inspector Expectation

Regulator / Inspector expectation (CQC): Inspectors expect medicines management to be safe, well-led and consistently implemented. They assess whether errors are investigated effectively, learning is embedded, and governance can evidence sustained improvement.

Operational Example 3: Repeated Recording Errors Indicating Weak Competency Assurance

Context: Multiple incidents were recorded where medicines were given correctly but MAR documentation was incomplete or inconsistent.

Support approach: RCA explored staff training history, observation records, audit effectiveness and management response to emerging themes.

Day-to-day delivery detail: Staff understood administration steps but were unclear on documentation standards, including reasons for non-administration, PRN rationale and “code” usage. Audits focused on missing signatures but did not explore why errors recurred. Supervision did not include observed practice review.

How effectiveness or change is evidenced: The provider introduced targeted competency re-checks for documentation, a simplified MAR guidance prompt, and audit escalation rules when repeat documentation issues occur. Evidence included reduced documentation errors, clearer PRN rationale notes, and improved staff confidence in medicines recording.

Embedding Medication RCA Learning Into Governance

Medication RCAs should produce governance outputs that commissioners and regulators recognise as credible. That includes:

Thematic analysis across incidents and near-misses
Clear actions linked to specific contributory factors
Timescales and named owners for changes
Post-action review to confirm effectiveness

When medication incidents trigger system redesign rather than blame, providers reduce harm risk, improve confidence and strengthen defensible assurance.