PrescQIPP

Contributory Factors Framework for Medicines Errors in Adult Social Care Settings (2025)

NHS England

Project summary

We produced a root cause analysis tool and interactive PDF guide to support investigating and learning from medicines errors in social care settings. This resource was adapted from a recognised root cause analysis model(1) and has been specifically tailored to meet the needs of adult social care providers. It was launched in December 2024.

Medicine errors are a significant burden in health and care settings in England, with social care contributing significantly to the overall burden(2). Medicines errors can result in serious or even fatal outcomes for people receiving care as well as impacting in those involved in the error. Conducting thorough and effective investigations into such errors is essential for learning and taking meaningful actions to prevent future incidents.

We recognised there was a lack of dedicated resources tailored to the Adult Social Care sector, so this framework and accompanying guidance was developed to help address this gap.

The content was reviewed by the Medicines & Pharmacy Northwest Steering Group, which includes representatives from Adult Social Care, Integrated Care Boards, NHS England, Care Quality Commission (CQC) and Safeguarding Teams.
These resources aim to:

  • Encourage broader thinking about the underlying cause of the error.
  • Support team leaders and line managers with their review process.
  • Promote a consistent, constructive & fair evaluation of the actions of staff involved
  • Encourage the incident reviewer to work with the staff involved
  • Enable staff to say WHY factors contributed and give them a voice.
  • Help identify HOW it can be prevented from happening again
  • Encourage working together and sharing the learning to make care services safer for the people being supported

The interactive PDF includes links to a range of additional resources, offering practical support and guidance for care providers. 

A central component of the framework is the emphasis on supporting staff involved in incidents. We acknowledge that errors can be distressing for staff who become the ‘second victims’ as part of the process. The guide provides suggestions for identifying contributory factors and outlines approaches to support affected individuals.

Importantly, the framework promotes a 'just culture'—balancing accountability with a deeper understanding of the underlying systemic, structural, and environmental factors that contribute to medicines errors. By addressing these root causes, providers can implement meaningful changes that enhance safety and quality of care.

The framework and its associated materials are available free of charge across England.

Feedback from adult social care providers, Integrated Care Board teams, and regulatory bodies has been overwhelmingly positive.

  1. https://improvementacademy.org/resource/yorkshire-contributory-factors-framework/
  2. Elliott RA, Camacho E, Jankovic D, et al Economic analysis of the prevalence and clinical and economic burden of medication error in England BMJ Quality & Safety 2021;30:96-105.