Posted by Faye Marks, Associate
Are poorly implemented electronic medication systems putting patients at risk?
The Healthcare Safety Investigation Branch (HSIB), a government funded organisation which conducts independent investigations of patient safety concerns in the NHS across England, has highlighted that poorly implemented electronic medication systems can result in potentially fatal medication errors.
A recent report, “Investigation into electronic prescribing and medicines administration systems and safe discharge”, produced by the HSIB has highlighted a ‘significant safety risk’ with electronic prescribing.
The report reviewed the case of 75 year old Ann Midson, who was left taking two different blood-thinning medications after a mix up at the hospital where she was receiving treatment for terminal cancer. Clinicians changed her usual blood-thinning medication whilst she was in hospital, but her pharmacy continued to prescribe her old medication, as the system hadn’t updated her details. Ann therefore continued to take both medicines, which doctors believe may then have caused an episode of internal bleeding.
The error with her medication was only picked up three days before her death, and 18 days after she had been discharged from hospital, by a hospice nurse who visited her at home.
Incomplete or incorrect use of electronic prescribing and medicines administration systems (eMPA systems)
The report highlights that whilst many NHS Trusts across England are using electronic medication systems, which aim to reduce medication errors, the incorrect or incomplete use of these systems could create further risks to patient safety.
The report found that often staff are not using all of the functions of electronic medication systems or are switching between using digital records and paper records, which increases the risk of crucial information being missed.
Lack of information sharing
Ann’s case also highlighted the routine lack of information sharing between NHS services, such as GP surgeries and pharmacies. She had been taking one blood-thinning medication on admission. This was stopped during her time at the hospital, but this message was not relayed to her local pharmacy and she continued to take both after leaving hospital.
Seven-day pharmacy service
The report also identifies that the availability of a seven-day hospital pharmacy service is crucial to support a digital system and pick up any errors quickly. The length of time it took in Ann’s case had a huge effect on both her and her family.
Ann’s daughter said:
“Not only were we grieving the loss of mum but also that she had to deal with the stress and upset of this towards the end of her life. She had to spend a lot of time within different parts of the NHS and all we ever wanted was for her to get the best possible care at every stage.
I am glad HSIB decided to investigate this topic using mum’s case – it was reassuring to know that her experiences wouldn’t be lost, and her story would be told. Knowing that this may prevent similar incidents happening to other families is the best legacy for my wonderful mum to leave and what she would have wanted.”
In the report the HSIB thanked Ann’s family for their ongoing support and involvement in their investigation.
Dr Stephen Drage, Director of Investigations at HSIB and intensive care consultant said:
“ePMA systems are a positive step for the NHS – research shows if implemented well they can reduce medication errors by 50%. Our report is highlighting the risks if e-prescribing is not fully integrated and doesn’t create the whole picture of the patient’s medication needs from when they arrive to when they return home. The more efficient the system, the better the communication is with the patients, families and between NHS services.
We recognise the challenges the NHS faces in implementing e-prescribing, but we also know how terrible the experience was for both Ann and her family. The safety recommendations we’ve made are asking for national bodies to provide trusts with a blueprint for what a good system and implementation should look like. This will mean ePMA systems are used to their full benefit, reducing the risk of serious harm to patients.”
A solicitor’s view
In my experience as a clinical negligence solicitor, errors involving medication are all too common in GP Practices, hospitals and pharmacies. I have seen many cases where patients have been prescribed or administered the either the wrong dose of medication or the wrong medication altogether.
These errors happen on a regular basis and research published by the University of Manchester and the University of York found that over 230 million medication errors take place in the NHS in England each year. Whilst most of these errors will cause little or no harm to patients, some medication errors can leave patient with permanent and debilitating injuries. On rare occasions they can be fatal.
These errors often occur when electronic medication systems are in place but also frequently occur in settings where they are not. I agree with Dr Drage that electronic systems, if used correctly, should drastically reduce the incidence of medication errors, as there is simply less room for human error.
The key to reducing errors though is to ensure that the electronic systems are properly implemented and staff are given appropriate training. In time, I am hopeful that that technology such as electronic medication systems will go a long way to help improve patient safety by reducing medication errors.
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