Campaigners today slammed the "shocking" treatment of elderly people living in care homes after research revealed seven out of 10 had been given the wrong drugs or doses.
Overworked staff, poor teamwork and a lack of training were leading to mistakes that could result in discomfort, pain and even death, according to the report.
Researchers from universities in Leeds, London and Surrey examined data from 256 residents in 55 care homes across England. Each resident was typically taking eight medicines each.
In some cases the medication was mislabelled while in others patients were given the wrong doses or no dose at all. Almost a third (30 per cent) of the drugs which should have been monitored for potentially harmful side-effects were not.
The study found that staff lacked knowledge of what medicines should be given with food, did not always know how to administer inhalers and did not order adequate supplies of drugs.
Researchers also carried out interviews with residential care home staff, doctors and pharmacists, finding evidence of doctors who were not accessible and did not know the residents, a high staff workload, a lack of training, drug round interruptions, lack of teamwork, inefficient ordering systems and inaccurate medicine records.
The report said: "It was clear from the interviews that no one took responsibility for the whole system.
"We often saw well-intentioned people doing their best but in an uncoordinated way."
The report, published in the journal Quality And Safety In Health Care, concluded: "The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned."
Andrew Harrop, head of policy for Age Concern and Help the Aged, said: "It is shocking that older people are still not receiving the correct help and support to take medication in care homes.
"Medication is a basic part of care for many older people and is essential to their health and wellbeing.
"This is just one of the many flaws in the current care system which can have a huge impact on the quality of life for many older people.
"Care home residents are entitled to the same standard of GP service as anyone else so errors that occur because the patient is never seen by a GP, or the GP being unfamiliar with their medical history, should not arise."
Peter Walsh, chief executive of Action Against Medical Accidents, said the study was evidence of "age discrimination".
He said: "I don't think people would put up with this sort of error if we were talking about a children's home or dealing with younger individuals.
"The fact that it's older people means sometimes the errors and their consequences aren't noticed at all.
"People often make the assumption it is an elderly gentleman or lady so they are going to die anyway."
He called for the tighter regulation of nursing homes, with regular doctor-led reviews of patient medication and more training for staff.
John Turk, chief executive of the National Pharmacy Association, said: "Health professionals, including pharmacists, are working hard to provide good care, but they need a clear framework in which to operate.
"We would urge Government to ensure local care is better co-ordinated by the NHS and to involve pharmacy in local planning and implementation."
Neil Hunt, chief executive of the Alzheimer's Society, said at least two-thirds of people in care homes have dementia, adding: "We would like to see more medicine reviews by pharmacists and clinicians to ensure medicines are used safely and effectively."
A spokesman for the Department of Health said: "The safety and quality of care is our top priority, which is why the Department of Health commissioned this study in order to understand the extent of any problems.
"We will now work with the Care Quality Commission (CQC) and others to take forward the important issues raised by this study.
"We have given the Care Quality Commission tough powers to inspect, investigate and intervene where any service is failing, including in relation to the management of medicines.
"The CQC is currently scoping a major review of healthcare for people living in care homes.
"It will include medication safety, which is one of their key priorities for this year.
"The review will take into account the findings of the research and will focus on strengthening weaknesses in the systems involving medication."Reuse content