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.
This issue (episode 2) focuses on:
the most common safety issues associated with measuring patient weight
steps to eliminate drug concentration confusion
understanding Patient Care Analgesia (PCA) by proxy.