Using Root Cause Analysis to Reduce Medication Errors and Strengthen MAR Governance

Medication errors remain one of the most common and highest-risk incident types in adult social care. They can lead to direct harm, safeguarding concerns, and significant reputational damage. Critically, medication incidents are rarely explained by “human error” alone. They typically involve system issues: unclear processes, weak competence assurance, poor shift organisation, inconsistent second checks, or gaps in oversight. Applying root cause analysis within robust quality standards and frameworks allows providers to identify contributory factors, strengthen controls, and evidence learning in ways that stand up to commissioner and CQC scrutiny.

This article sets out how to use RCA to reduce medication risk and build defensible medication governance, with real operational examples and measurable assurance.

What a High-Quality Medication RCA Must Cover

A medication RCA should examine more than the immediate event. A defensible review typically covers:

• People factors: competency, confidence, fatigue, supervision, agency familiarity
• Process factors: MAR design, PRN protocols, second checks, ordering and stock control
• Environment factors: interruptions, storage layout, timing pressures, privacy
• Governance factors: audit quality, follow-up, escalation to leadership, trend reporting

The purpose is to identify where the system failed to prevent or detect error, and what controls must change.

Operational Example 1: Missed Dose Due to Shift Handover Failure

Context: A service user missed an evening dose because it was assumed “already given” during a busy shift change.

Support approach: RCA reviewed the handover structure, MAR signing conventions, and role allocation during medication rounds.

Day-to-day delivery detail: Handover notes referenced “meds done” but did not specify which individual. The MAR had an empty box but no “not administered” code or explanation. Staff were splitting tasks informally, and the second checker was diverted to another priority. Interruptions during the round increased reliance on memory rather than record-based confirmation.

How effectiveness or change is evidenced: The provider introduced a named medication lead per shift, a mandatory MAR exception code for omissions, and a structured handover prompt requiring confirmation of medication status for each person supported. Evidence included fewer MAR ambiguities on audit, improved completeness of omission rationales, and reduced repeat incidents linked to handover assumptions.

Using RCA to Improve PRN Decision-Making

PRN (as required) medication can generate recurring incidents when decision thresholds are unclear or staff confidence varies. RCAs should test whether PRN protocols are:

• Written in plain English and accessible during shifts
• Linked to observable indicators and non-pharmacological strategies
• Supported by competency assessment (not just training attendance)
• Reviewed routinely with clinical oversight where required

Operational Example 2: PRN Administered Without Clear Rationale

Context: A PRN sedative was administered during heightened anxiety, but records did not show what alternatives were tried or why the PRN threshold was met.

Support approach: RCA reviewed the PRN protocol, staff competency, PBS alignment, and documentation expectations.

Day-to-day delivery detail: Daily notes described “agitated” without behavioural descriptors. The PRN section of the MAR lacked space for rationale, and staff were not consistently recording antecedents, de-escalation attempts, or post-administration outcomes. Supervision records showed medication competence was discussed generally but not observed in practice.

How effectiveness or change is evidenced: The provider updated PRN protocols with observable indicators and required recording of alternatives tried. They introduced an attached PRN rationale sheet (or equivalent prompt), and implemented observed competency checks for PRN decisions. Evidence included improved rationale quality, clearer “what worked” documentation, and fewer repeat RCA themes around PRN defensibility.

Commissioner Expectation

Commissioner expectation: Commissioners expect providers to evidence safe medication systems through measurable assurance: audit regimes, competency assessment, incident trend analysis, and clear escalation when risk thresholds are breached. They also expect learning to translate into consistent day-to-day practice across teams.

Regulator / Inspector Expectation

Regulator / Inspector expectation (CQC): Inspectors expect providers to show robust medicines management: accurate records, safe administration, clear PRN governance, effective investigation of incidents, and demonstrable learning. They will look for triangulation between MAR audits, incident analysis, training/competence records and supervision oversight.

Operational Example 3: Stock Control and Ordering Failures Leading to Omitted Medication

Context: Medication was omitted because a repeat prescription had not been ordered in time, and there was no contingency plan for out-of-hours supply.

Support approach: RCA examined ordering responsibilities, pharmacy liaison processes, and governance oversight of stock levels.

Day-to-day delivery detail: The service relied on one person to place orders, without a clear deputy arrangement. Stock checks were informal and recorded inconsistently. When the pharmacy queried an item, the follow-up action was not tracked, and the issue became visible only when the medication ran out. Staff did not have a clear escalation route for urgent supply.

How effectiveness or change is evidenced: The provider implemented a two-person ordering process with a deputy, a weekly documented stock check, and a tracked “queries log” for pharmacy follow-ups. They also clarified out-of-hours escalation steps. Evidence included reduced omitted-dose incidents linked to stock, cleaner ordering records, and stronger audit outcomes on stock governance.

Governance Controls That Prevent Repeat Medication Incidents

Medication governance should go beyond “monthly audit scores”. Strong controls include:

• Targeted auditing: audits focused on known weak points (PRN rationale, omissions coding, second checks)
• Competency assurance: observed practice checks, not just e-learning completion
• Trend reporting: themes from incidents and near-misses reviewed at governance forums
• Action verification: evidence that changes have embedded (follow-up sampling, supervision notes, repeat audits)

Making “Learning” Measurable

A defensible approach to evidence includes:

• Reduction in repeat contributory factors across RCAs (not just fewer incidents)
• Improved MAR audit sub-scores (for example, omissions rationale, PRN recording, second checks)
• Competency pass rates and observed-practice outcomes
• Clear escalation evidence (when thresholds are breached)

When medication RCA is used as a governance tool—linking incidents to controls, assurance and measurable outcomes—providers can demonstrate safer practice and stronger organisational grip.

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