An unseen patient rests their hand on a hospital bed, with an unused cannula inserted on the top of their hand.

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

HSIB legacy content

HSIB legacy content

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

National investigation

Research suggests that 237 million medication errors occur at some point in the medication process in England per year.

When errors occur in prescribing high-risk medications for older patients with multiple medical problems, there is a significant risk of serious harm. High-risk medicines are those which risk significant patient harm or death when used in error, such as warfarin.

Reference event

The reference event in this investigation is an incident where a hospital inpatient was administered repeated doses of warfarin in error and suffered significant harm as a result. The error was detected after six days by a ward-based clinical pharmacist.

Investigation summary

This patient safety investigation looks at the:

  • Systems and processes which underpin the identification, prescribing and administration of warfarin for older inpatients.
  • Main patient safety risks arising from the prescribing and administration of warfarin and other high-risk drugs.
  • Main patient safety defences that act to protect people from medication errors with high-risk medicines.
Investigation report