The Healthcare Safety Investigation Branch has launched an investigation into an incident where a patient was inadvertently prescribed and administering two anticoagulation medications.  This occurred immediately following discharge from hospital, over a weekend.  It took 15 days for the error to be detected.

The investigation will focus on:

  • The impact of electronic prescribing and medicines administration (EPMA) systems on the safe discharge of patients, capturing the primary and secondary care interface and communication with the patient/family.
  • The influence of weekend working on patient safety, in the context of the availability of support services and specialist input. 

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