The report is the third and final report in a series of investigations exploring patient safety events in NHS organisations to understand why patients may not have received medications as planned.
This particular investigation explores the systems and processes in place to support when patients are discharged into the community with medications. The investigation also explores the role played by electronic prescribing and medicines administration (ePMA) systems and electronic patient record systems (EPR) in supporting care in this area.
Patient case
In the case we examined, a 53-year-old patient was admitted to hospital after a fall. Whilst in hospital a change was made to his diabetes medication. He was given support/education on self-administration, but six days after he left hospital, he had a follow up with the diabetes team and told them he was unable to remember all the information about his medication.
He was already receiving wound and catheter care from a district nurse, so the team made a referral via his GP for district nursing to support his self-administration. However, the district nursing team were not made aware of the referral and 17 days after being discharged from hospital, he told the district nurse he had not been taking his insulin. A glucose reading was taken and was high enough to prompt him to be taken via ambulance back to the hospital for treatment and observation overnight.
Gaps in patient records
The investigation highlighted specific concerns around gaps in patient records and the loss of critical information between hospitals and primary/community care. It also reinforced the importance of ensuring patients are properly educated and feel comfortable and confident when discharged from hospital, especially if they have to manage their own medication needs.
While the investigation focused on a single case involving a diabetic patient, the findings offer valuable insights that can inform wider discussions and drive safety improvements across the NHS.
Key findings
Some of the more detailed key findings in the case included:
- On the patient’s admission, conflicting information in his patient records created challenges for staff in understanding whether he was taking any medication to manage his diabetes.
- The patient’s individual circumstances were considered by the hospital diabetes specialist nursing team when arranging education for self-administering his insulin. However, there was no documentation available to establish whether the patient was able to effectively self-administer his insulin after the education and manage his diabetes during the rest of his inpatient stay.
- The patient’s need for district nursing support for insulin administration was documented and interpreted differently by different hospital teams, and between hospital and district nursing teams.
- The processes for managing medications on the ward and in the hospital’s discharge lounge did not identify that the patient was discharged home with two insulin pens, including one he did not need. This resulted in confusion for the patient about which one he should use.
- A mismatch between demand and capacity within the district nursing service often led to visits being overscheduled and time restrictions during patient visits.
- Multiple healthcare providers were involved with the patient’s care. They used different electronic patient record (EPR) systems that did not interact to share information about the patient’s care and referral status.
The report concludes with comprehensive local-level learning prompts to help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. The prompts cover care in hospital, discharge planning and care in the community.
Investigator’s view
Rebecca Doyle, Safety Investigator at HSSIB, says: “While individual cases can be complex, this incident clearly highlighted persistent challenges with information sharing — an issue we continue to see in investigations that explore communication and the interaction of digital systems. This information sharing is critical to keep people safe at home, managing their medical conditions and avoiding readmission to hospital.
“It also underlined the importance of education and tailored support in hospital, to ensure patients don’t miss or delay critical medication, particularly when they need to self-administer. In this case, the patient’s emergency readmission after not taking his insulin shows the real potential for harm when these systems don’t work as intended.
“The insights and analysis presented in the report, along with the learning prompts, offer valuable guidance — not just for trusts and providers, but also for those working at a national level on discharge planning and improving the interoperability of electronic patient record systems. Ultimately, improving information flow and patient support at discharge is not just an administrative task — it’s a matter of patient safety.”
Related articles
Electronic patient record systems: recurring themes arising from safety investigations
Read article
Report highlights impact of emergency departments missing or delaying ‘time critical’ medication for patients with existing conditions
Read article
Investigation finds patients suffer harm as electronic communications fail to support their safe discharge from hospital
Read article