HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department (5 December 2024)

Summary

This is the first in a series of Healthcare Services Safety Investigation Body (HSSIB) investigations exploring why medications intended to be provided to patients are not given. Patients who need medications can suffer harm if these are not provided.

The investigation explored the systems and processes in place to support staff to recognise, prescribe and administer time critical medications in the emergency department (ED). Time critical medications are medications that must be given at specific times of the day to ensure they are fully effective. The investigation also explored the role played by electronic prescribing and medicines administration (ePMA) systems in supporting care in this area.

To explore these issues, the investigation used a patient safety event involving a patient aged 85 with Parkinson’s. The patient usually took his own medication (self-administered) at home – two doses of Parkinson’s medication four times a day, at set times – to help control his symptoms.

Content

The patient safety event

The patient had attended hospital for an outpatient appointment where he mentioned he had back pain following a fall at home the previous day. He was advised to attend the ED and went there immediately after his outpatient appointment.

The patient spent 3 days in the ED. During this time he should have received a total of 18 doses of his Parkinson’s medication, which was a time critical medication. However, seven doses were not given and three doses were given late. This meant that only 8 of 18 doses of Parkinson’s medication were provided to the patient on time.

The patient was transferred to a medical ward where his Parkinson’s symptoms deteriorated and he lost the ability to swallow. The patient died 4 weeks after his admission to the ward. The causes of death identified on his death certificate included bronchopneumonia (severe chest infection), Parkinson’s, and frailty of old age.

Findings

• The patient required time critical medication for Parkinson’s but did not receive, or received late, 10 of 18 doses during his time in the ED. The coroner reported Parkinson’s as a factor leading to the patient’s death.
• There were no defined roles or responsibilities in the ED to ensure patients who required time critical medications were identified, and medications prescribed, as soon as possible.
• The ED had no dedicated pharmacy support to help staff in providing care to patients who required time critical medications.
• The patient spent 52 hours in the ED; for 44 of these he was cared for in a corridor because of demand on ED services. Corridor care created additional challenges for ED staff and specialty teams and may have limited opportunities to store the patient’s medication which he had brought from home.
• The Trust did not participate in the Royal College of Emergency Medicine Quality Improvement Programme on time critical medication.
• The ePMA system did not include a function to alert staff about patients who required time critical medications to be prescribed or administered.
• An outage in the ePMA system meant the patient required both an electronic and paper prescription chart. This may have caused additional confusion about the patient’s medication.
• Staff had adapted their practice to ensure they could effectively use the ePMA in the ED setting. This was because of challenges in accessing computers and medication rooms in the ED environment.
• The patient self-administered some doses of his Parkinson’s medication, but this was not planned and self-administration by patients was not widely supported by clinical staff or local guidance.
• Staff were not able to check neurology clinic letters because there was a backlog in these letters being uploaded to the electronic patient record system.
• Staff were not able to check information with the patient’s GP practice or Parkinson’s specialty team at the time the patient’s medication was prescribed in the ED, as this was outside of these services’ working hours.
• Staff received contradictory information from the patient’s son and the GP summary care record about the dosage of medication the patient required. The GP summary care record was taken as the most accurate record, but the information it contained was incorrect.
• Once the patient’s medication information was entered onto the ePMA system, no further attempt was made to contact the GP practice or Parkinson’s specialty team to confirm it was correct.
• Some information about the patient’s medication within the GP patient record was transferred to the GP summary care record, but other information was not.

Safety observation

• NHS trusts can improve patient safety by using the information contained in the information pack for the Royal College of Emergency Medicine’s Quality Improvement Programme on time critical medications to assess their preparedness and make local improvements in identifying, prescribing, and administering time critical medications in emergency departments.

Local-level learning prompts for acute hospitals

Delays in identifying and prescribing time critical medication in the ED

• How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED?
• Who in your patient pathway is responsible for identifying patients who need time critical medications?
• Who in your patient pathway is responsible for prescribing time critical medications?
• How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed?
• What aids or tools are available in your organisation to help staff to identify patients who need time critical medications?
• What pharmacy support is available to staff in ED to support in the care of patients who need time critical medications?

Missed and delayed doses of time critical medication in the ED

• How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?
• How does your organisation support patients to self-administer time critical medications, when appropriate?
• How does your organisation capture information when patients self-administer time critical medications?
• How does your organisation receive and consider information from families and carers to help avoid missed or delayed doses of time critical medications?

ePMA systems and time critical medication in the ED

• How does your ePMA system help to alert staff to patients who need time critical medications?
• How does your organisation train staff to use local ePMA systems and record when patients require time critical medications?
• How does your organisation prepare and support staff to work safely when ePMA systems may not be functioning to ensure time critical medications are not missed?
• How does your organisation audit delays or omissions in time critical medications and use this to improve delivery of time critical medication?
• Is your organisation aware of any adaptations that staff are required to make to ensure they can use the ePMA system effectively in local environments?

Further reading on the hub:

• Professionals with Parkinson’s tackle time critical patient safety issue: a blog by Sam Freeman Carney
• Parkinson's UK: Time critical medication guides for health professionals
• Medication delays: A huge risk for inpatients with Parkinson’s