Incomplete use of electronic medication systems, such as electronic prescribing and medicines administration (ePMA), can risk patient safety, a report from the independent Healthcare Safety Investigation Branch (HSIB) has found.
The report, ‘Electronic prescribing and medicines administration systems and safe discharge’, published on 24 October 2019, followed an incident that led to a patient taking two anticoagulants at once owing to a lack of information shared about the patient’s medicines on discharge from hospital.
In the case, a 75-year-old woman with incurable cancer, who was already taking the anticoagulant dalteparin for atrial fibrillation, was admitted to hospital.
On discharge, her prescription for dalteparin was stopped on the trust’s ePMA system and she was prescribed apixaban instead. However, on visiting her local pharmacy after being discharged, she still received her repeat prescription for dalteparin. This followed an order of dalteparin submitted the previous week, which she then took on top of the newly prescribed apixaban.
The error was detected 15 days after discharge by a hospice nurse and both medicines were stopped by the patient’s GP. She died three days later, although her death was not caused by the error.
The HSIB said the example highlighted the risks to patients cared for by more than one healthcare provider, caused by errors in communication between providers using different systems for patient records and prescriptions.
“ePMA systems are a positive step for the NHS — research shows if implemented well they can reduce medication errors by 50%,” said Stephen Drage, director of investigations at HSIB.
“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 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.”