Using technology in care homes – eMAR



Medicines errors in care homes are unacceptably high. A key study found that residents taking seven or more medicines had a 79% chance of being victim of a medicines error (Alldred et all 2009).


Best practice in medicines record keeping

The management of medicines in nursing and residential homes is part of a highly complex pathway.  It involves multiple staff groups and organisations.

These include the G.P.; all who prescribe medicines and treatments; Care Staff of all grades; Support Workers; Consultants: Specialist Practitioners; and the Pharmacies who supply the medicines.

Benefits of electronic MAR charts

The benefits of implementing electronic MAR charts fall into three categories.

  1. Improved legibility.
  2. Improved access (e.g., if the charts are accessed and updated on a computer or portable device there is less risk of losing, damaging, or mislaying them).
  3. eMAR chart systems that obtain the data taken directly from the Community Pharmacy system eliminate the need for transcribing, which is a high-risk area.

In addition to the three benefits mentioned, carefully planned, and implemented eMAR systems contribute to a decrease in medicines errors, reduced administrative costs and improved quality of care.

Challenges of implementing electronic MAR charts

There are three ‘bottom line’ challenges to manage when transitioning to electronic MAR charts.

1. Assessing the way the system works is critical, as poorly designed will not deliver benefits, and eventually fail.

The system must be easy to use and jargon free, using only approved acronyms or mnemonics.

Electronic systems also offer the opportunity to introduce features which enhance safety, some of which, such as time ordered charts, are difficult to include in a paper-based system.

Here’s a checklist:



2. It is vital that the system handles patient consent; patient confidentiality, system access; ownership of patient identifiable data; storage and transfer of data in a way which is compliant with the laws and regulations of your part of the U.K. This is an important question for you to pose to the supplier, particularly with the advent of General Data Protection Regulation (GDPR), and the new Data Protection Act 2018.



3. It is important to look at current processes and how the new system will work. There have been problems where acute prescriptions were needed and supplied by a different pharmacy from the one providing the MAR charts, so the home ended up at times with an electronic MAR and a paper MAR. This causes confusion and increases the risk of errors and/or omissions. Colleagues have told me of instances where this has led to eMAR systems being abandoned.

Training and support requirements

Quality training and support, both during the implementation and on an ongoing basis, underpin all successful healthcare I.T systems, and need to be planned from the outset. There are four areas which are sometimes overlooked that deserve special mention.

1.  Many of the users of eMAR systems will be Healthcare Assistants or other non-registered skilled staff. As a result, it will be important that the training they receive reinforces their duty to keep accurate records, and their accountability and role is made clear.

2. A substantial number of staff may speak English as a second language. Therefore, it is important that eMAR systems do not use any unnecessary jargon, and that any help text is in plain language.

3. Appropriate knowledge of Data Protection (GDPR) and Information Governance Rules and regulations are essential and should be built into any training programmes.

Overall, consideration needs to be given to the nature and content of the training needed to implement the system, including how this is linked to the policies and procedures and overall governance of the home.

Good suppliers will be able to give advice and support on this.


Record keeping in medicines management is a critical safety area for care homes. The current high level of medicines errors is in care homes affect half a million people in England.

The prospect of implementing electronic systems for recording medicines administration holds great potential but is not itself without risk. It needs to be approached carefully in the light of the complex arrangements and multiple organisations involved in prescribing, supplying, administering, and monitoring medicines in care homes.

In time, electronic systems will become the norm for medicines management in care homes.

Given the considerations over choice and implementation of systems, eMAR can overcome problems of legibility, transcribing, and access to records and information in a way which is not possible with paper systems.

In years to come it is likely that, just as most G.P.’s would not want to return to paper systems, care homes will come to see electronic systems in the same way. The main beneficiary of this will be the residents in terms of improved safety.

This, in turn, will benefit care home staff who will no longer be involved in the risky business of sorting out, transcribing and chasing paper records. Care home providers will also benefit through decreased indirect costs associated with more efficient and safer processes.

Reference: Alldred P, Barber N, Buckle P et al (2009) Care home use of medicines study (CHUMS): Medication errors in nursing and residential care homes – prevalence, consequences, causes and solutions. Report to the Patient Safety Research Portfolio. Department of Health, London.
 Steve Turner was Information Governance Lead and Data Protection Officer for CareMeds Ltd

Blog last Updated: 21.03.2022

Managing Medicines in Care Homes. Implementing NICE Guidance and Quality Standards.


Managing Medicines in Care Homes. Communication and sharing medicines information. Implementing NICE Guidance and Quality Standards.

Steve Turner reflects on the communication challenges facing nursing and residential homes around implementing NICE Guidelines and Quality Standards and offers some practical advice.

Quality Standards on managing medicines in care homes from the National Institute for Health and Care Clinical Excellence in England (NICE) link to the NICE Guidance on Managing Medicines in Care Homes, which contains 118 recommendations.

This blog post offers suggestions on how to go about achieving quality standards, focusing specifically on communication and timely sharing of accurate medicines information.

The findings are based on experiences of related quality improvement [QI] projects.

By working closely with front line staff in care homes, we have been able to identify and pilot some key changes. Then spread the learning.

As part of this approach, we have produced an alternative checklist on managing medicine in care homes.
Managing medicines checklist:


By focusing on these questions at the outset, issues around best practice in medicines management can be identified.

These questions are particularly important due to the large number of people involved in the care of residents, which includes their G.P.; Specialist Nurses; Visiting Health Professionals; Pharmacists, Therapists, Hospitals and Outpatient Consultants.

Good quality management of medicines relies on all parties sharing information in a timely and auditable way. Much of this is outside the direct control of the care home.

Here’s two real life examples of things care homes can do to improve communication and promote best practice.

Example 1 – Knowledge of medicines and what are they being given for?

There are two principal areas to consider here.

Knowledge of medicines:

Firstly, how much detail should staff know about the medicines residents are taking?

There are many medicines which need to be given in a specific way, e.g. with food, before food, after food, dependent on the pulse rate etc.

Often more specific instructions apply, such as for alendronic acid, which is usually given for osteoporosis. These tablets must be swallowed whole and the person taking the medicine must remain upright for a period of time afterwards. This is because the tablet is acidic and will damage the stomach wall if it doesn’t pass through it quickly. So, if a resident is unable to take the tablet as directed, and therefore isn’t letting it pass through the stomach quickly, advice from a clinician as is needed straight away.

Another example of something where a basic knowledge of the medicine is needed is with the SSRI group of antidepressants (e.g., citalopram). Although these drugs aren’t addictive, they are medicines which need to be taken consistently and, if stopped abruptly (not tailed off), will often cause ‘discontinuation’ symptoms. These symptoms may include giddiness and very distressing feelings such as electric shock type sensations. If the resident is not able to express themselves easily their distress could be misinterpreted when they start to refuse to take it, or the supply has run out.

Information on each medicine is not always easily available. An answer to this is to ensure basic information leaflets on the medicines taken by residents are readily available to staff relatives and (wherever appropriate) to the resident, either in print, or online. A useful source of clearly written short medicines information leaflets is available at .

Your local Pharmacy or Medicines Management Team, Specialist Nurses or G.P. will be able to give advice on the most appropriate patient information sheets, many of which are also available in easy read format and in other languages.

What are the medicines being given for?

Secondly, when giving out medicines, do staff, residents and relatives know what each medicine is being given for? NICE Guidance specifies that information on medicines and their indication (what they are being given for) should be readily available to all those involved in the management of medicines. In practice this isn’t an item which appears on most Medicines Administration Records (MAR charts). Neither is it always shown on the pharmacy label, which only lists exactly what the doctor has written on the prescription.

Why is this important? These differences can be significant, and lead to serious mistakes, if this information is missing.

Firstly, for completeness and safe care I believe it’s unacceptable not to have this information readily to hand. All patients (and / or those caring for them, and acting on their behalf), whether this is in a care home or the person’s home, should be given this information, in order that the person (or their representative) can be part of a shared decision-making process on the choice of medicines.

Secondly, visiting professionals and clinicians, out-of–hours and emergency services need to know this information to be able to assess and treat the residents safely. Many medicines can be given for different conditions often with a different dose range.

An example is amitriptyline which, if you look it up, is an anti-depressant; however, it is also given in lower doses for neuropathic pain, and sometimes used for irritable bowel syndrome.

Another example is lithium which is frequently prescribed as a mood stabiliser, it can also be prescribed, in particular circumstances, to enhance the effect of anti-depressants. Unless the reason for the prescription is known and easy to find things can go wrong. I have known clinicians to stop lithium inappropriately because the records were incomplete.

When working as a Community Mental Health Nurse I once visited someone who had attempted suicide, who explained that she was driven to it because she was taking an antidepressant and it ‘wasn’t working’. In fact, she had been prescribed amitriptyline for pain at a low dose, much lower than would be effective for depression.

In the longer term shared electronic medicines records are the most appropriate and robust solution. Prior to this, there are several things which will make the relevant information more readily available to all who need it.

At the risk of telling Granny how to suck eggs, here’s a checklist of interventions we are piloting as part of quality improvement projects:

1. Always query incomplete directions on medicines, either with the Pharmacy or the G.P.

2. When medicines are reviewed ask specifically for information on what they have been prescribed for, and record this.

3. Fax (or preferably email) medicines queries to G.P. Surgeries in order to keep a record of them. (This also means that people are not interrupted by ‘phone calls, don’t have to pass a verbal message on, and can consider the reply more fully.)

Example 2 – Records of communication between different services and professionals

Residents medicines are often managed by several professionals, for example the G.P. may prescribe based on information from a Psychiatrist, Specialist Nurse, Physiotherapist, Speech Therapist, Dietician, or Non-medical Prescribers may change, stop or add medicines themselves when they visit the home.

Residents may also be prescribed a variable dose drug such as warfarin, where the dose is monitored and prescribed by a separate service. Some residents may also be seeing private clinicians, or receiving alternative therapies which need to be known to other prescribers.

Diets and dietary supplements too must be communicated to all prescribers, and this may have a significant effect on the absorption of medicines. The same is true for the resident’s posture, mobility, and state of hydration, so all clinicians need to be aware of problems in these areas.

Complex information about medicines is frequently recorded is a variety of places, and these records are not always complete, particularly when something changes outside of the standard review cycle.

We’ve been looking at this more closely with staff in homes as part of an action learning process, and came up with the following recommendations:

1. If discharge information on medicines is incomplete raise this with the hospital concerned in writing, and (especially if this happens repeatedly) and ask for information on what will be done to correct this problem in the long term. This need is reinforced by a patient safety alert issued by NHS England on ‘timeliness of communication with primary and social care when patients are discharged from hospital’.

2. When visiting professionals carry out an assessment and ask care home staff to contact the resident’s G.P., ask them to put this in writing. This avoids the possibility of mixed messages and enables a written record to be kept without duplication of effort.

3. When G.P.s visit the home to carry out reviews, prepare a structured written list of residents needing attention in advance of the visit.


Implementing Guidance and Quality Standards on medicines management in care homes can seem like a daunting task. By working closely with staff in the homes and starting out with some broad questions, things which need to be changed can be identified and worked through in a systematic way.

Many of the difficulties around communication lie outside the direct control of the care home, as a result communication and information sharing need to be looked at jointly.

Residents benefit from the homes taking a lead in insisting on full medicines information from prescribers, to ensure safety. This involves remaining steadfastly assertive in pointing out when information is incomplete.

  • Key areas to focus on around communication are:
    • Does everyone (residents, staff, representatives, and relatives) know what each medicine is being given for?
    • How are changes to medicines (i.e. starting, stopping, dose alterations and requests for reviews) communicated?

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Version 3 . Updated: 21.03.2022

Disruptive innovation works!



Being a disruptive innovator is hard to start with and may not fit into the standard tendering process, and you may appear to conflict with existing hierarchies.

Although I try to avoid jargon and avoid buzz words and fads, I think ‘disruptive innovation’ is probably a good description of work my Associates and I have been involved in.

You may find that the final product isn’t what you originally thought it was going to be, and it may take a long time for the beneficial changes to become accepted and spread.

In the end the benefits to patients and the public speak for themselves and it’s a hugely rewarding undertaking.

Some examples:

Childrens’ medicines safety

A successful interdisciplinary, multi-organisational prescribing project and the development of a parent held medicines record for children in the community with complex conditions.

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This work was published as a NICE shared learning example, was highly commended at the NICE Conference in 2005. It has had a lasting legacy.


Helping patients lead on their own care

My Associates and I have also developed, and successfully piloted, ‘patient led clinical medicines reviews’.


This novel approach involves medicines education session for patients, followed by the opportunity for people to review their medicines in a 3/4 hour session with two health professionals. It is published as a NICE shared learning example .

It’s listed on the NICE Shared Learning pages here:

I spoke on Managing care for patients with multimorbidities – case studies of implementing NICE guidance at the 2018 NICE Annual Conference.


Implementing safer prescribing in substance misuse

A successful inter-disciplinary project to implement non-medical prescribing across a substance misuse service. This project included developing and implementing an interdisciplinary / cross organisational medicine governance process.


This project was presented at the national NHS Change Day event in 2012 and published in the Nurse Prescribing Journal.

Ref: Introducing nurse prescribing in a substance misuse treatment service (Nov 4, 2012) Nurse Prescribing 2012 Vol1 10 No 11


Turning Up The Volume! for patient safety

In 2014 set up the Turn Up The Volume! patient safety movement, the aim of which is to promote best practice in patient safety through listening openly to concerns of patients, staff, carers and relatives, and taking actions together.


Dr Steve Bolsin talking at Turn Up The Volume! 2 London 2017

We have held two successfully open events and been influential in shaping NHS initiatives on ending the need for whistleblowing in relation to patient safety. I have presented on this at a number of national and local events, including a Health Education England ‘Future of Medical Education’ Conference in 2016 and at Barking Havering and Redbridge University Hospitals NHS Trust, as part of their dignity at work month.


Author: Steve Turner    07931 919 330   @MedicineGovSte

Join in with #MedLearn – and follow @MedicineGov


Version 2 : 09/07/2019


Medicines Optimisation – what does this mean to patients?? (5 minute read)

Medicines Optimisation and shared decision making are frequently used buzzwords – what do these terms mean in practice?? – here’s some patient stories to reflect on:

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These stories are fictitious but based on real events:

Ben’s holiday – (finding out what a medicine does by accident) :

Ben is a 16 year old boy who has been prescribed a drug for a behavioural condition, it’s a powerful drug (called an antipsychotic) which he has taken for over a year. His parents think it helps. Ben hasn’t said what he really thinks, but accepts the tablet.

A few years ago the family went on holiday to Poland. During the holiday there was an air traffic controller’s strike. The family were stuck overseas waiting for the strike to end. They ran out of Ben’s medicine and were unable to obtain any or anything similar. As a result, out of desperation, they gave Ben a saccharin tablet instead, and hoped for the best. He was fine. Over the next few weeks they even noticed an improvement in his mood and behaviour. He seemed to be enjoying life more. When the family returned to the UK they stopped giving him the ‘placebo’ tablets, and he has not needed to take medicines since.

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Ian’s secret: (in jargon this is ‘intentional non-adherence’)

Ian is a 35 year old man diagnosed with bipolar disorder. When Ian moved to another part of the country he was allocated a new community psychiatric nurse [CPN] and, as he was unwell at the time, was re-started on medication. Over the next 18 months Ian’s condition improved so his CPN reported a ‘good response to the medication’. It was only after 2 years of knowing him that Ian confided in his CPN that he didn’t take the medication consistently, and never had.

The medicine was lithium, which requires regular blood tests. This is because too much of it is toxic and too little has no effect. Ian revealed that he had only taken it before his blood test days, then always stopped taking it in between.

Ian’s medical notes had stated that he always ‘responded well to lithium’!

As a result of Ian being able to trust his CPN, and let on that he wasn’t taking it, his medical records were corrected to say that he did not want to be prescribed lithium, confirming that other options worked much better. These options include some medicines which he had previously ‘borrowed’ from someone else, or bought on the internet. Of course he didn’t tell medical staff about this at the time.

So his choice is now clearly written up, should he become unwell again.

…and now the ‘science bit’. If you want them I can provide references for medicines geeks like me!

Medicines Optimisation is a powerful term because it brings in the:

  •    Patient’s views and their decision

Clinical people may think they ‘know best’, but in the end it is  the patients (you and I) who will decide whether or not we take the medicine, and we will not always tell the doctor or nurse if we don’t feel we can trust them. Statistically around 50% of people, (all ages all types of people), don’t take their medicines as prescribed.

  • The ‘human factors’ and health beliefs related to having to take medicines

Medicines aren’t always the answer. We may have strong beliefs in favour or against them; these beliefs are hard to change and need to be respected. Basically we usually know what’s right for us.

  • The ‘evidence base’, which means is it known to work?

People who prescribe medicines (usually doctors, pharmacists or nurses who have the qualification) need to offer the medicines which are proven to be most effective. And there is often a choice.

Repeatedly studies have shown that clinicians have a list of medicines they prescribe for various illnesses in their minds, and this list may bear little or no relation to the evidence available on what works best.

Medicines optimisation is not simply another term for ‘medicines management’, which is generally used to refer to the mechanics of the medicines process. This leads us to consider not just the process of selecting, prescribing; ordering; supplying; administering and monitoring, but also whether the person has the capacity and enough knowledge to decide to take a medicine; if they actually take the medicine and indeed whether the medicine is needed in the first place.

Sometimes people need multiple medicines (referred to as polypharmacy) because of the complexity of their illnesses. This can be inappropriate if, for example, a medicine is simply added to counteract the side-effects of another medicine.

I will be speaking on Managing care for patients with multimorbidities – case studies of implementing NICE guidance at the 2018 NICE Annual Conference

Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University and former NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @MedicineGovSte 


Version 1   Added 12/02/2018 Amended 15/11/2019 & 02/02/2022

Nurse & former patient teaching together as equals

Shared decision making in mental health.


‘Such a great lecture one of the best since I’ve started Uni’

A workshop session delivered jointly by a facilitator and a user of mental health services

Comments from our students:

‘Thank you. It is always much more real and interesting when taught by someone with real experience, as opposed to theories. Really useful’.

‘It was great to hear Sam’s personal experiences and hear how Steve related them to practice.’

In these sessions you can ask us both anything.

Join us on YouTube.

Aim of the session:

To discuss adherence to medicines and treatments; relate this to practice through group work and discuss this with a user of mental health services

Example learning outcomes (can be tailored to individual needs):

• To be able to relate theory to practice and give examples of techniques to achieve adherence

• To be able to describe the key issues around adherence and shared decision making

• To be able to define compliance; concordance and adherence and why these are helpful terms

• To have the opportunity to ask questions directly to a user of services and a front line clinician

Comments from attendees include:

• Real life experience better learning environment

• Fascinating and very brave to explain one’s highs and lows to strangers. Thank you x

• Great hearing first-hand experience

• Good balance of theory and practice

• Sam’s talk was brilliant and really helpful

• Brilliant having opportunity to speak to someone who has been through it

• Found the opportunity to question a service user very beneficial. To hear first-hand what he found good and bad during his experience in the mental health system

• The user of services sharing their views on meds, treatment and compliance, concordance and adherence

• Shared info. from a person with own experience & what he identified are characteristics that made a good nurse & the honesty of his own concordance with meds.

• (appreciated) Your honesty

• Providing insight into personal experiences and services

• Nice to hear someone speak honestly about concordance from a service user’s perspective, especially from not taking meds.

• Learning in-depth about adherence, concordance and compliance

• The way our guest was talking about his experience was great, very interesting; honest …just real

To book a session email: 

Steve Turner and his company Care Right Now CIC has been involved in innovative healthcare projects, several of which have achieved national recognistion in the UK – click here for more information.

Feedback and views welcome, send them to

Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and a former NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s on social media here: 


Click on the image to find out more about @MedicineGov & #MedLearn

Author: Steve Turner

Added: 25.01.2021