A healthcare professional taps a tablet computer.

Electronic prescribing and medicines administration systems and safe discharge

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Reference event

The reference event in this investigation is the case of a 75-year old woman.

She was left taking two powerful blood thinning medications after a mix-up at her local hospital, where she was receiving treatment for incurable cancer. She died from her cancer 18 days after being discharged from hospital and three days after the error with her medication was picked up.

Investigation summary

Increasingly, many NHS trusts across England are taking up ePMA technology to improve medicines safety. This investigation highlights that incomplete use of ePMA systems could create further risks to patient safety.

The investigation found that:

  • Often all the functions of ePMA systems are not used.
  • Staff switch between using paper and electronic records, increasing the likelihood of missing crucial information.
  • There is routine lack of information sharing between NHS services, such as GP surgeries and pharmacies.
  • Availability of a seven-day hospital pharmacy service is crucial to support an ePMA system and pick-up errors quickly.
Investigation report