HSIB has identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding.
Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks, risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation.
- It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System.
- It is recommended that NHSX supports the development of interoperability standards for medication messaging.
- It is recommended that 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.
- It is recommended that 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.
- It is recommended that 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.
- It is recommended that NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.