The report sets out a case where a medication error with warfarin contributed to the death of a 79-year-old man. The patient had suffered a fall at home and had been admitted to hospital. An error on his chart whilst he was on the ward led to him receiving four or five doses of warfarin, which he did not normally take, before the error was spotted by a ward-based clinical pharmacist. The patient developed internal bleeding and deteriorated (due to several health reasons) and died 21 days after his first admission.
Research published this year suggests that medication errors may directly cause around 712 deaths per year and indirectly contribute to 1,708.
Complex pharmaceutical care
The report highlights the growing ageing population and that pharmaceutical care of older people can be complex. They are often taking multiple medications and are at the greatest risk of harm due to medicine-related errors.
In the case HSIB examined, the patient was on 12 different medications and supplements at the time of admission. By day nine of his hospital stay, this had increased to 16.
Role of ward-based clinical pharmacy services
Our national investigation focused on the role of ward-based clinical pharmacy services and how they work within the multidisciplinary teams (MDTs) that administer care to a patient.
Ward-based pharmacists are crucial in enhancing the team's ability to spot errors, especially in high-risk situations. However, the investigation findings emphasised that there is variance in the way the services are staffed and organised. They also found that other staff within the MDTs could better understand the role pharmacists have in between admission and discharge of the patient.
We also found that more work needs to be done to assess how resilient pharmacy services are to operational pressures and the additional challenges associated with caring for older people.
As a result of the national investigation, HSIB has made three safety recommendations to facilitate better understanding of the role of the ward-based pharmacist, and to encourage best practice and resilience when identifying and developing models of pharmacy provision.
Dr Stephen Drage, HSIB’s Director of Investigations and ICU consultant, said: “Medication errors are one of the most frequent failures of care and it can have a devastating outcome, as sadly shown by the case that launched our investigation.
“Through our investigation it emerged that collaboration within MDTs is key. Better understanding the role of the ward-based pharmacist and the expertise they bring can help reduce medication errors, especially in high-risk situations.
“The safety recommendations set out in the report focus on ensuring a national approach to modelling pharmacy services, giving trusts the best chance to increase their healthcare resilience. This is now more important than ever as the NHS tackles COVID-19 and the extra pressure the pandemic is putting on services.
“Medication errors are more likely to occur when patients are older, or have complex needs, but they can impact any patient. Increasing the efficiency and effectiveness of pharmacy services can help to reduce the risk of error and ensure consistency of care for all.”
Read the report
For more information, download and read the high-risk prescribing errors report.