Electronic prescribing and medicines administration systems and safe discharge
HSIB Legacy
Published
Medication
Access to care
We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems. An ePMA system supports the safe, effective, and cost-effective use of medicines from a patient’s admission to hospital until their discharge.
6 recommendations
9 observations
1 action
5 of 6 responded
Safety Recommendations (6)
NHSX
R/2019/050
It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System.
NHSX agrees with the recommendation to develop a process for acting on digital issues reported from the Patient Safety Incident Management System and has drafted a process, planning to develop it further with NHS England.
We acknowledge and agree with the report’s recommendation that a process should be developed to recognise and act on digital issues reported from the Patient Safety Incident Management System. In response to this recommendation we have drafted a process and plan to work alongside NHSE [NHS England and NHS Improvement] to fully develop this.
NHSX
R/2019/051
It is recommended that NHSX supports the development of interoperability standards for medication messaging.
NHSX has defined interoperable medication standards and is establishing an interoperable medicines programme to prioritize and support the adoption and implementation of these standards.
Regarding the report’s recommendation that NHSX supports the development of interoperability standards for medication messaging, we have now defined interoperable medication standards and are working towards setting up an interoperable medicines programme to support the adoption and implementation of standards as a priority, working at a pace which the vendor market is able to support.
R/2019/055
It is recommended that NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.
NHSX agrees to produce guidance. They are currently updating transfer of care messaging specifications and will consider commissioning specific guidance on ePMA interface once that update is complete.
We acknowledge and agree with the report’s recommendation that NHSX produce guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process. We are currently updating the transfer of care messaging specifications to support the dose syntax. Once completed we shall consider commissioning specific guidance on the ePMA interface. We are happy to work in partnership with provider organisations to overcome any potential obstacles regarding modernisation and utilisation of standards and future guidance. Responses received on 17 January 2020.
Department of Health and Social Care
R/2019/053
It is recommended that the Department of Health and Social Care should consider how to prioritise the commissioning of research on human factors and clinical decision support systems; particularly in relation to the configuration of software system alerting and alert fatigue, to establish how best to maximise clinician response to high risk medication alerts.
The department has completed initial scoping and defined research requirements. The recommendation is now in an internal prioritisation process, to be completed by March 2020, to agree next steps for research commissioning.
Since publication of the HSIB report in October 2019, the Department of Health & Social Care has been working with national partners (such as NHSX, NHS England & Improvement, and the National Institute for Health Research) to discuss the report recommendation. This includes, how research might focus also on the design fundamentals of clinical decision support within ePMAs (e.g. designing out specific errors, thereby making software ‘alerts’ to the clinician unnecessary). This work produced a detailed definition of the policy, service and research requirements, key policy and research questions, and potential methodological approaches. This initial scoping work was completed in January 2020, and the recommendation will now proceed through the Department’s internal research prioritisation processes. This Departmental prioritisation process is currently underway, and it will be completed in March 2020. At that point, possible next steps for delivering research that address the HSIB recommendation will be agreed, and the Department can start work with our national partners to undertake relevant research commissioning activity. The Department will provide a further update, including timescales, when these details are known. Response received on 17 January 2020.
NHS England
R/2019/054
It is recommended that NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines use.
NHS England and NHS Improvement have incorporated shared decision making and patient information into their Medicines Safety Improvement Programme, supporting patient campaigns, pharmacist training, and developing the NHS Medicines A-Z website.
We understand how important it is for professionals and patients to make shared decisions about medication. It reduces risk and helps make sure that medicines are used safely. In this way it supports all the other efforts that the Medicines Safety Improvement Programme is making to reduce errors. Our early work has built shared decision making into the programme in three ways: By backing patient led campaigns for better communication, such as ‘Me & My Medicines’, and ‘Choosing Wisely’, an initiative that takes into account what’s important to the patient as well as the clinician. By training pharmacists to improve their face to face communications with patients. By providing information for the public about how specific medicines work, how and when to take them, possible side effects and answers to common questions, on the NHS Medicines A-Z website . Actions As part of the NHS Patient Safety Strategy and in response to the WHO 3rd Global Challenge – Medication without Harm, The Medicines Safety Improvement Programme has identified shared decision making and information for patients as key deliverables to improve patient and medicines safety. Our early work here is focussed in three main areas: Firstly supporting, with widespread communication, models of shared decision making such as ‘Choosing Wisely’ and ‘Me & My Medicines’. Secondly, by collaborating with the National Clinical Director for Personalised Care, in delivering training for pharmacists in shared decision making as part of a larger programme. Thirdly, the development of the NHS Medicines A-Z , led by NHS Digital, to provide web-based information relating to specific medicines written specifically for patients. Response received on 13 January 2020.
R/2019/052
It is recommended that NHSX continues its assessment of the ePRaSE pilot and considers making ePRaSE a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines administration safety.
Safety Observations (9)
The use of paper and electronic systems in parallel should be minimised to reduce the risk of error caused by multiple data entry/retrieval sources.
The practice of documenting only newly prescribed medication on discharge summaries should be reviewed from a patient safety and medicines management perspective.
Counselling of patients newly commenced on a direct oral anticoagulant is critical to the safe use of these medicines. It would be helpful if NHS trusts reviewed this practice paying particular consideration to the communication of changes in medication and the initiation of new medication
There may be benefit for healthcare professionals to receive training in handover communications which should include integrating clinical information with full medicines information, and to share this information with patients and carers in writing and verbally.
During the implementation of any new digital system, benefits may be realised by redesigning work practices to ensure the new system is fully embedded, with staff training/engagement to support this.
It would be beneficial to the users of electronic prescribing medicines and administration systems if the system vendors raised awareness of the safety limitations of their products and had a system for collating safety feedback to inform future development and a mechanism for sharing feedback with other users.
The processes for medicines reconciliation in the community would benefit from being reviewed, taking into account the intent for practice-based pharmacists outlined in NHS England’s Long Term Plan (NHS England, 2019).
Summary Care Records
National, peer-reviewed, standardised lists of alerts for clinical decision support systems should be the gold standard, to enable consistency of approach and to promote evidence-based safety improvements.
Decision support systems in sectors other than healthcare
In acute trusts where digital systems are in place, the prioritisation of medicines reconciliation and medication reviews supports the consistent delivery of these core functions, across seven-day services.
Safety Actions (1)
The National Academic Health Science Networks Medicines Optimisation Network has been commissioned by NHS England to support the roll-out of Transfers of Care Around Medicines across England.