Badly implemented electronic systems putting NHS patients at risk
pharmafile | October 24, 2019 | News story | Business Services |
A new report has warned that poorly implemented electronic medication systems in the NHS could potentially lead to fatal medication errors.
The Healthcare Safety Investigation Branch (HSIB) looked at the case of 75 year old Ann Midson who was left taking two powerful blood thinning medicines after a mix-up at her local hospital where she was also receiving treatment while suffering from incurable cancer.
Ann died 18 days after being discharged and the medication error was only noticed three days before this.
The report itself highlights that many NHS trusts across England are utilising electronic prescribing and medicines administration (ePMA) systems which if used inappropriately could create further risks to patient safety.
Many NHS trusts across England have taken up this new technology with the prime reason that they reduce medication errors however, the report found that all the functions of the ePMA system is not being used and doctors and nurses often switch between paper records and digital records thereby increasing the likelihood of key information and criteria being missed.
The report ultimately sets outs several recommendations about the better sharing of information as well as improved communication, medication messaging and alerts to ensure the safe discharge of patients.
The recommendations are:
- That NHSX develops an improved process to recognise and act upon digital issues reported in the Patient Safety Incident Management System
- The support of development for interoperability standards for NHS messaging apps.
- The institution of a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines safety.
- NHS England and NHS Improvement include in their Medication Safety Programme improved patient access to medical information to ensure patient-centred approaches that are safe and effective.
- The NHSX is to produce new guidance on the electronic discharge process as well as how electronic prescribing should be interfaced with such a process.
