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 a 75-year old woman.

She was left taking two powerful blood thinning medications after a mix-up at her local hospital, where she was receiving treatment for incurable cancer. She 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 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.

All organisations responded to their safety recommendations within 90 days of publication of the investigation report.

NHSX

Safety recommendation

It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System.

Response

We acknowledge and agree with the report’s recommendation that a process should be developed to recognise and act on digital issues reported from the Patient Safety Incident Management System. In response to this recommendation we have drafted a process and plan to work alongside NHSE [NHS England and NHS Improvement] to fully develop this.

Safety recommendation

It is recommended that NHSX supports the development of interoperability standards for medication messaging.

Response

Regarding the report’s recommendation that NHSX supports the development of interoperability standards for medication messaging, we have now defined interoperable medication standards and are working towards setting up an interoperable medicines programme to support the adoption and implementation of standards as a priority, working at a pace which the vendor market is able to support.

Safety recommendation

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.

Response

In response to the report’s recommendation on assessing the ePRaSE pilot, we have completed said pilot and have identified a number of accessibility challenges. We are now focused on learning from the initial pilot, so that we can initiate an extended Alpha phase pilot in May 2020 before making any final decision on the full adoption of the tool.

Safety recommendation

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.

Response

We acknowledge and agree with the report’s recommendation that NHSX produce guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process. We are currently updating the transfer of care messaging specifications to support the dose syntax. Once completed we shall consider commissioning specific guidance on the ePMA interface.

We are happy to work in partnership with provider organisations to overcome any potential obstacles regarding modernisation and utilisation of standards and future guidance.

These responses were received on 17 January 2020.

Department of Health and Social Care

Safety recommendation

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.

Response

Since publication of the HSIB report in October 2019, the Department of Health & Social Care has been working with national partners (such as NHSX, NHS England & Improvement, and the National Institute for Health Research) to discuss the report recommendation. This includes, how research might focus also on the design fundamentals of clinical decision support within ePMAs (e.g. designing out specific errors, thereby making software ‘alerts’ to the clinician unnecessary).

This work produced a detailed definition of the policy, service and research requirements, key policy and research questions, and potential methodological approaches. This initial scoping work was completed in January 2020, and the recommendation will now proceed through the Department’s internal research prioritisation processes.

This Departmental prioritisation process is currently underway, and it will be completed in March 2020. At that point, possible next steps for delivering research that address the HSIB recommendation will be agreed, and the Department can start work with our national partners to undertake relevant research commissioning activity. The Department will provide a further update, including timescales, when these details are known.

This response was received on 17 January 2020.

NHS England and NHS Improvement

Safety recommendation

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.

Response

We understand how important it is for professionals and patients to make shared decisions about medication. It reduces risk and helps make sure that medicines are used safely. In this way it supports all the other efforts that the Medicines Safety Improvement Programme is making to reduce errors. Our early work has built shared decision making into the programme in three ways:

  1. By backing patient led campaigns for better communication, such as ‘Me & My Medicines’, and ‘Choosing Wisely’, an initiative that takes into account what’s important to the patient as well as the clinician.
  2. By training pharmacists to improve their face to face communications with patients.
  3. By providing information for the public about how specific medicines work, how and when to take them, possible side effects and answers to common questions, on the NHS Medicines A-Z website.

Actions

As part of the NHS Patient Safety Strategy and in response to the WHO 3rd Global Challenge – Medication without Harm, The Medicines Safety Improvement Programme has identified shared decision making and information for patients as key deliverables to improve patient and medicines safety.

Our early work here is focussed in three main areas:

  • Firstly supporting, with widespread communication, models of shared decision making such as ‘Choosing Wisely’ and ‘Me & My Medicines’.
  • Secondly, by collaborating with the National Clinical Director for Personalised Care, in delivering training for pharmacists in shared decision making as part of a larger programme.
  • Thirdly, the development of the NHS Medicines A-Z, led by NHS Digital, to provide web-based information relating to specific medicines written specifically for patients.

This response was received on 13 January 2020.

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