The Healthcare Safety Investigation Branch (HSIB) has published an interim bulletin for its investigation looking at identifying and reducing high-risk prescribing errors in hospital.

Interim bulletins are released to share further details for each investigation, including how it’s met HSIB criteria, the history of the event it relates to, the national context and any identified safety issues.

National context

Academic research suggests that over 200 million medication errors occur within the NHS in England every year. Errors were more likely to be noted in older people, or in the presence of co-morbidity and polypharmacy. Co-morbidity is where more than one illness or disease occurs in one person at the same time. Polypharmacy is the use of multiple medicines by one person.

Older people were also more likely to be at risk from an adverse drug reaction. Where adverse drug reactions occur this has led to increased hospital lengths of stay, costs of hospital care and patient mortality. Warfarin is more frequently prescribed in older patient groups and is frequently associated with medication errors.

Safety issues identified

The initial investigation considered that there may be a specific risk related to the administration of high-risk medicines to frail, elderly patients in hospital. Further investigation has identified specific risks associated with medication prescription and that these risks are not limited to the prescription of high-risk medications in isolation.

The following safety issues will form the basis of the wider investigation:

  • The systems and processes which underpin the prescribing of medication for older people admitted to hospital.
  • The main patient safety risks arising from the prescribing of warfarin and the safety defences in place.
  • The common pressures that may impact on clinical practice and the identification of drug prescribing errors.

Ongoing investigation

Our investigation continues to explore the identified safety issues and welcomes further information that may be relevant, regardless of source. 

We’ll report any significant developments as the investigation progresses.

For more information please download the interim bulletin or visit the ‘identifying and reducing high-risk prescribing errors in hospital’ investigation page.

Sign-up for investigation email alerts by contacting enquiries@hsib.org.uk.