• Health Safety Investigation Branch launched investigation after an elderly patient was mistakenly given two strong anticoagulant medications 
  • E-prescribing error meant pharmacy had not been informed of cancelled prescription
  • Clinicians switching between use of paper and electronic records could lead to “crucial” information being missed, HSIB warns

Poorly-implemented electronic prescribing systems in NHS hospitals are putting patients’ lives at risk, the NHS’s safety watchdog has warned.

A report published this week by the Health Safety Investigation Branch found that poor use of e-prescribing systems “could create further risks to patient safety”.

This warning follows an incident in which an elderly patient, Ann Midson, mistakenly took two powerful blood-thinning medications for two weeks after an e-prescribing error meant her community pharmacy was not informed one of the prescriptions had been cancelled.

Trusts across NHS England have been strongly encouraged to implement e-prescribing systems as they can reduce medication errors if used correctly. Two years ago Keith McNeil, NHSE’s first chief clinical information officer, told HSJ: “If boards are not incentivised by the fact that they are putting their patients at risk they need to be sacked.”

However, HSIB report concluded that failing to use e-prescribing properly could create further risk to patient safety.

It said that a seven-day pharmacy service was “crucial” in supporting a digital system and highlighted “the routine lack of information sharing” between NHS services. HSIB called for NHSX to “support the development for interoperability standards for medication messaging”.

HSIB also warned of the dangers of clinicians switching back and forwards between the use of digital and paper records as this “increases the likelihood of crucial information being missed”.

Further recommendations included better medication messaging and alerts to ensure the safe discharge of patients from hospital.

Director of investigations at HSIB Dr Stephen Drage, said: “[Electronic prescribing and medicines administration 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.

Terrible experience

“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.”

Mrs Midson, who was diagnosed with terminal lung cancer and kidney cancer in August 2017, was admitted to hospital in March 2018 with vomiting, worsening shortness of breath and difficulty swallowing. She already took a self-administered injection of anti-coagulant medication – dalteparin - for a heart condition that had been diagnosed several years earlier.

While Mrs Midson was in her local hospital – which is not named in the report - a clinician cancelled the dalteparin prescription via an e-prescribing system and she was prescribed an oral medication, apixaban, instead. However, the community pharmacy was not informed the dalterparin prescription had been cancelled and replaced as it was not digitally linked to the e-prescribing system.

The investigation also found that while dalteparin was cancelled following “verbal communication during the ward round” there was “no written documentation” in Mrs Midson’s record that showed the decision had been discussed with her.

When Mrs Midson was discharged from hospital she received her usual dalteparin prescription from the pharmacy, which she continued to take along with apixaban. The error was not identified until 15 days after Mrs Midson had been discharged from hospital. After learning about the error, a GP cancelled both prescriptions.

A spokesman for the Department of Health and Social Care said: “We want the NHS to be the safest healthcare system in the world, which is why we set up HSIB to highlight areas where safety can be improved.

“We will consider the recommendations to promote patient safety published in the recent report and reply in due course.”

NHSE has been approached for a comment.