The Healthcare Safety Investigation Branch (HSIB) has conducted an independent investigation into patient safety concerns in healthcare that result from problems within the systems and processes in relation to ePMA (electronic prescribing and medicines administration).
The report warns poorly implemented ePMA systems can result in potentially fatal medication errors.
It comes after the body looked at the case of 75-year old Ann Midson, who was taking two powerful blood thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer. Ann sadly died from her cancer 18 days after being discharged and the error with her medication was only picked up three days before. This led to the HSIB investigation.
The report highlights that many NHS trusts across England are taking up ePMA as they reduce medication errors, but that 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.
The report also identifies that the availability of a seven-day hospital pharmacy service is crucial to support a digital system and pick up any errors quickly.
Dr Stephen Drage, Director of Investigations at HSIB and an ICU consultant said “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.”
“We recognise the challenges the NHS faces in implementing e-prescribing, but we also know how terrible the experience was for both Ann and her family. The safety recommendations we’ve made are asking for national bodies to provide trusts with a blueprint for what a good system and implementation should look like. This will mean ePMA systems are used to their full benefit, reducing the risk of serious harm to patients.”
The report sets out several recommendations around better information sharing and communication:
- NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System.
- NHSX supports the development of interoperability standards for medication messaging.
- NHSX continues its assessment of the ePRaSE pilot and considers making ePRaSE a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines administration safety.
- The Department of Health and Social Care should consider how to prioritise the commissioning of research on human factors and clinical decision support systems; particularly in relation to the configuration of software system alerting and alert fatigue, to establish how best to maximise clinician response to high risk medication alerts.
- NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines use.
- NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.
