Poorly implemented electronic medication systems in the NHS can result in potentially fatal medication errors, a new report warns.
The report comes after the Healthcare Safety Investigation Branch (HSIB) looked at the case of 75-year old Ann Midson, who was left 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 to question why this happened, even when the hospital had an electronic prescribing and medicines administration (ePMA) system in place.
The report highlights that many NHS trusts across England are taking up this technology 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.
Ann’s case also highlighted the routine lack of information sharing between NHS services, such as GP surgeries and pharmacies. She had been taking one blood thinning medication on admission. This was stopped during her time at the hospital, but this message was not relayed to her local pharmacy and she continued to take both after leaving hospital.
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. The length of time it took in Ann’s case had a huge effect on both her and her family.
The report sets out several recommendations around better information sharing and communication, improving medication messaging and alerts to ensure the safe discharge of patients. They are:
- 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.