Aim and objectives. To compare medicine administration by two nurses to a patient with swallowing difficulties and: * • To assess the safety of medication administration to a patient with dysphagia. * • To explore possible system changes to ensure safety standards are understood and adhered to. Background. Administering medicines to patients with dysphagia is complex and nurses need to understand the complexities and safety issues of administering polypharmacy. Design. Undisguised observational study. Method. Undisguised observation was used to collect data on two nurses giving medicines to one patient on separate occasions. Root cause analysis was used to compare and contrast the two incidents to gain an understanding of how nurses interpret and administer multiple medicines to a patient with dysphagia. Results. Administration of medicines by both nurses was not optimal. Several factors conspired to cause this, in particular insufficient staff numbers and skill mix together with inadequate knowledge of how to administer medicines safely to patients with dysphagia. Conclusions. The findings identify the need for continuing professional development (CPD) in medicine administration to provide greater understanding of the contraindications of combining medications and of the legal implications of altering formulations. Relevance to clinical practice. Administering medicines to patients with dysphagia is complex and requires knowledgeable understanding and attention to detail. Clinical areas caring for this client group must be well staffed with skilled, knowledgeable staff if medicines are to be given safely. This requires CPD in administering multiple medications to ensure legal and safety aspects are adhered to.