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24.10.19

Healthcare Safety Investigation Branch warns partial set up of electronic medication systems in NHS puts patients at risk

“Poorly implemented” electronic prescribing and medicines administration systems (ePMA) can result in potentially fatal medication errors, a report by the Healthcare Safety Investigation Branch (HSIB) warns today.

The report follows the case of a 75-year-old cancer patient, Ann Midson, who sadly died after taking two powerful blood thinning medication after a mix-up at her local hospital where she was receiving treatment for her incurable cancer.

She died from her cancer 18 days after being discharged, and the error with her medication was only picked up three days before.

The report highlights that with many NHS trusts across England are using this technology as they reduce medication errors, the incomplete use of E-Systems could create further risks to patient safety.

The investigation found that often all the functions of ePMA systems aren’t being used and that staff switch between using paper record and digital records, increasing the likelihood of crucial information being missed.

Ann’s case also illustrated the lack of information sharing between NHS services, such as GP surgeries and pharmacies. She had been taking one blood thinning medication on admission. The medication was stopped during her time at the hospital, but this message was not passed onto her local pharmacy and she proceeded to take both after leaving hospital.

Ann’s daughter said: “Not only were we grieving the loss of mum but also that she had to deal with the stress and upset of this towards the end of her life. She had to spend a lot of time within different parts of the NHS and all we ever wanted was for her to get the best possible care at every stage. 

“I am glad the HSIB decided to investigate this topic using mum’s case - it was reassuring to know that her experiences wouldn’t be lost, and her story would be told. Knowing that this may prevent similar incidents happening to other families is the best legacy for my wonderful mum to leave and what she would have wanted.”

The report sets out numerous recommendations around more efficient information sharing and communication, improving medication messaging and alerts to guarantee the safe discharge of patients.

Dr Stephen Drage, director of investigations at HSIB and an ICU consultant says: ePMA systems are a positive step for the NHS – research shows if implemented well they can reduce medication errors by 50%. Our report is highlighting the risks if e-prescribing is not fully integrated and doesn’t create the whole picture of the patient’s medication needs from when they arrive to when they return home. The more efficient the system, the better the communication is with the patients, families and between NHS services.”

 

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