Report highlights electronic prescribing risks

  • Date: 30 October 2019

ELECTRONIC medication systems can put patient safety at risk if not properly implemented, according to the findings of an investigation report by the Healthcare Safety Investigations Branch (HSIB).

The report found that the functions of ePMA (electronic prescribing and medicines administration) systems are often not fully used and that staff switch between using paper records and digital records, increasing the likelihood of crucial information being missed and leading to potentially fatal medication errors.

The report comes after the HSIB looked at the case of a 75-year-old patient who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment for an incurable cancer. She died from her cancer 18 days after being discharged and the medication error was only picked up three days before, despite the hospital having had an ePMA system in place.

The HSIB report also highlighted a routine lack of information sharing between NHS services, such as GP surgeries and pharmacies, and the importance of a seven-day hospital pharmacy service to support a digital system and to pick up any errors quickly. The report recommends improved medication messaging and alerts to ensure the safe discharge of patients.

Dr Stephen Drage, Director of Investigations at HSIB and an intensive care consultant, says: "ePMA systems are a positive step for the NHS – research shows if implemented well they can reduce medication errors by 50 per cent. 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.

"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."

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