Medication related harm

We have completed three local investigations and a national investigation that look at medication related harm.

Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. This can include an irreversible deterioration in symptoms that the medication was controlling and death.

These investigations explore the safety issues associated with medication not given. HSSIB was told of many instances where patients do not receive the medication they need whilst in hospital, at home or in a nursing home.

With advances in technology most NHS hospitals now use electronic prescribing and medicines administration (ePMA) software. ePMAs have been shown to reduce some medication errors. However, they can introduce different errors if they are not well understood and do not support staff in the task of prescribing and administering medicines. The way ePMAs are used varies both within and between hospitals which can cause problems for NHS staff.

Local investigations

The three locality-based patient safety investigations, with actions aimed at specific NHS trusts, each focus on a different area of the patient pathway, including a change in healthcare setting.

These investigations were carried out at three different NHS trusts:

• Medication not given: administration of time critical medication in the emergency department
• Medication not given: anticoagulation before and after a procedure
• Medication not given: discharge from an acute hospital to the community

National investigation

This investigation focuses on procurement of new ePMA functionality and/or upgrades of existing ePMA functionality and how patient safety learning related to ePMA is identified and shared across the healthcare system.

• Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals