We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems.

An ePMA system supports the safe, effective, and cost-effective use of medicines from a patient’s admission to hospital until their discharge.

Reference event

The reference event in this investigation is the case of 75-year old Ann Midson.

Ann was left taking two powerful blood thinning medications after a mix-up at her local hospital, where she was receiving treatment for incurable cancer. Ann died from her cancer 18 days after being discharged from hospital and three days after the error with her medication was picked up.

Investigation summary

Increasingly, many NHS trusts across England are taking up ePMA technology to improve medicines safety. This investigation highlights that incomplete use of ePMA systems could create further risks to patient safety.

The investigation found that:

  • Often all the functions of ePMA systems are not used.
  • Staff switch between using paper and electronic records, increasing the likelihood of missing crucial information.
  • There is routine lack of information sharing between NHS services, such as GP surgeries and pharmacies.
  • Availability of a seven-day hospital pharmacy service is crucial to support an ePMA system and pick-up errors quickly.

Download and read the full report.

Safety recommendations

We’ve made safety recommendations to NHSX, the Department of Health and Social Care and NHS England and NHS Improvement as a result of this investigation.

The safety recommendations ask for these national bodies to provide NHS trusts with a blueprint for what a good ePMA system and implementation should look like. This will mean ePMA systems are used to their full benefit and reduce the risk of serious harm to patients.

We expect these organisations to respond to their safety recommendations within 90 days of the publication of the investigation report. Their responses will be shared here when they’re available.


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 [ePrescribing Risk and Safety Evaluation] 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 NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.

Department of Health and Social Care

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.

NHS England and NHS Improvement

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.

Find out more by reading our report launch news story.