Medication related harm

How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED?

Who in your patient pathway is responsible for identifying patients who need time critical medications?

Who in your patient pathway is responsible for prescribing time critical medications?

How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed?

What aids or tools are available in your organisation to help staff to identify patients who need time critical medications?

What pharmacy support is available to staff in ED to support in the care of patients who need time critical medications?

The first eight doses were not prescribed during the patient’s first 24 hours in the ED. The patient self-administered the first four doses.

When the medication was prescribed, the morning dose was incorrect.

A dose was prescribed but not given on day 3.

How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?

How does your organisation support patients to self-administer time critical medications, when appropriate?

How does your organisation capture information when patients self-administer time critical medications?

How does your organisation receive and consider information from families and carers to help avoid missed or delayed doses of time critical medications?

How does your ePMA system help to alert staff to patients who need time critical medications?

How does your organisation train staff to use local ePMA systems and record when patients require time critical medications?

How does your organisation support staff to work safely when ePMA systems may not be functioning to ensure time critical medications are not missed?

How does your organisation audit delays or omissions in time critical medications and use this to improve delivery of time critical medication?

Is your organisation aware of any adaptations that staff are required to make to ensure they can use the ePMA system effectively in local environments?

How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed?

How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication?

Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused?

Does your organisation have a process for ensuring that guidelines that cross-refer to other relevant guidelines are reviewed together to ensure they provide consistent advice?

How do you ensure that all members of the multidisciplinary team with relevant expertise are included in clinical guideline reviews?

Does your organisation have processes in place to ensure that when new evidence on newer anticoagulants becomes available it is considered for inclusion in local guidance as soon as possible?

How does your organisation support staff to find and readily access anticoagulation related guidelines?

Does your organisation ensure it is easy for staff to access information in patients’ records relevant to decision making about anticoagulant medication?

Does your ePMA system identify patients with paused time-critical medication that may warrant a review?

How does your organisation consider factors relating to equipment which may affect the successful implementation of EPR/ePMA systems?

How does your organisation support staff to quickly and easily identify what medication a patient is currently taking and their medication history?

How does your organisation make sure that patients have access to specialist diabetes support including out of hours?

How does your organisation support staff to gain an understanding of the care patients with diabetes need?

How does your organisation ensure that education given to patients emphasises the importance of taking insulin and is appropriate and tailored to their individual needs?

How does your organisation support patients to feel confident and safe in self-administration of insulin?

How does your organisation support patients to understand how to raise concerns about self-administration of insulin?

How does your organisation consider family, carer or living arrangements when providing education on self-administration?

How does your organisation support staff to ensure that medications for an individual patient that are no longer needed are disposed of safely?

How does your organisation support staff to complete medication checks before patients are discharged home with medications?

How does your organisation follow up with patients post discharge, whose insulin regimen has started or been changed while in hospital?

How does your organisation work with other services to help provide co-ordinated care for patients discharged home who need insulin support?

How does your organisation support staff to identify and be able to refer to local diabetes specialist services when patients are discharged home?

Does your organisation support staff to make timely and effective referrals to district nursing services to support insulin administration?

How does your organisation enable staff to understand that a patient referral has been received, actioned, and completed?

How does your organisation ensure enough time is allocated to district nursing visits based on individual patient needs?

How does your organisation support staff to take rest breaks and reduce the risk of staff fatigue?

How to adjust the insulin dose was discussed, as well as injection technique. The patient was given leaflets which detailed injection technique and what to do in the event of illness, and type 2 diabetes and healthy eating booklets were also provided. 2.3 The patient was advised that the diabetes specialist nursing team would follow up during the week to help with altering the insulin dose if needed. The patient was discharged from the care of the diabetes specialist nursing team to the general medicine care team. Day 6 2.4 The patient continued to receive general medical treatment to support his wellbeing in readiness for his discharge home. It was noted in his records that discharge would likely be planned for the following day. 2.5 A note was added to the patient’s records in relation to his diabetes which included a plan for his discharge. This was to: ‘continue with prescribed insulin of 10 units in the morning and 10 units in the evening, 20 minutes before food titrate [adjust] the insulin [dose] 10% to 20% if blood glucose high or low continue with oral diabetic medication monitor blood glucose levels before meals arrange a post discharge telephone review’. Day 7 (discharge home) 2.6 At around 18:00 hours the patient was discharged home from the hospital and a referral was made to the district nursing team. The referral was made via a message taking service (which involves the healthcare professional calling a phoneline service and leaving a message with details of the referral, which is then passed on to the community team to action) and the patient was already known to the district nursing service. The referral was sent to the community trust’s planned service team. 2.7 The referral stated that the patient had a catheter which needed changing every 9 weeks, that he required insulin ‘twice daily 8am and 6pm’, and would need wound care. The visits were requested to start from the day after discharge. The records stated that a medication directive (instructions for administering medications when a patient has a specific need) was given to the patient to pass to the district nursing teams, along with a discharge letter. Day 8 2.8 The message taking service followed up with the district nursing team to check that the referral had been received. It was confirmed that it had and no further action was taken. A visit from the district nursing team did not take place on this day. The patient contacted the district nursing service to request a visit for wound care and the patient was scheduled a visit. Days 9 to 20 2.9 The patient was seen by the district nursing team for wound care starting on day 9. Home visits continued every 2 days by different members of the district nursing team to provide wound care. The patient required additional care for some catheter issues between planned visits. The visits did not include administration of insulin. 2.10 On day 13 the hospital’s diabetes nursing team had a follow-up telephone call with the patient. It was noted during the conversation that the patient was ‘unable to remember all the information after discharge’ and since going home, had not taken the insulin or monitored his blood glucose. 2.11 The patient was asked to contact his GP to arrange for his blood glucose to be checked and to arrange district nursing support to administer the insulin. In the meantime the patient was advised to continue taking oral (taken by mouth) medication to help manage his diabetes. 2.12 Following this conversation, a letter was also sent by email to the patient’s GP requesting the patient be reviewed ‘urgently’ and district nursing support be arranged ‘as soon as possible’ to help with insulin administration. 2.13 Plans were made for the patient to have a diabetes review but there were no entries in the GP records to suggest the district nursing team’s referral had been actioned. 2.14 The district nurses continued to provide wound care. There was no documentation in the patient’s records about any discussion relating to his insulin medication. Day 21 2.15 The patient had a fall at home and the urgent community response team visited him. The records stated that a ‘review of meds undertaken and metformin [a type of medication used to treat diabetes] identified and confirmed’. The patient did not have any injuries following his fall and was supported to stay at home. Day 22 2.16 In the early afternoon, the patient was visited at home. He had requested a visit via the district nursing unplanned service because he was having issues with his catheter (a tube used to drain urine from the bladder). A bladder washout was done and no further concerns were noted. 2.17 Later that evening the patient contacted the out of hours service again because of issues with his catheter. A member of the district nursing evening service visited him. During this visit it was identified that the patient had been prescribed insulin following his recent stay in hospital but had not had any since he was discharged home. It was noted in his records that he ‘was unsure how to administer. Was shown in hospital but unsure of doses’. The nurse documented there was an ‘odd’ insulin pen in the patient’s discharge bag from hospital and this was not prescribed. 2.18 The district nurse took the patient’s blood glucose reading, which was high. The nurse arranged for him to be taken to hospital by ambulance. The patient was assessed and kept in overnight for observation before being discharged home the following day. The patient was initially supported at home by the district nursing service to self-administer his insulin, and now continues to self-administer insulin himself to manage his diabetes. 3. Analysis and findings The investigation explored the factors that may have led to the patient not receiving his insulin for 15 days after he was discharged from hospital. The investigation met with a range of staff involved in the patient’s care, not all of whom could recall the specifics of the patient’s care because of the length of time that had passed since the event. Therefore, the investigation mainly used documented information and an exploration of how care is usually delivered. The investigation explored the care given under the following headings: Care in hospital Planning for discharge in hospital Care in the community Electronic patient record (EPR) and electronic prescribing and medicines administration (ePMA) systems. This section includes local learning prompts, which aim to help organisations improve the safety of patients who are being discharged from an acute hospital to the community. 3.1 Care in hospital Medication checks on admission 3.1.1 Differing information was obtained on admission about how the patient was managing his diabetes. One of the hospital records stated he was not taking any medication for his diabetes before his admission, while other hospital records stated he was prescribed metformin. It was not clear from the records where the history was obtained. The investigation heard from several staff interviewed that it was not unusual for there to be conflicting information due to how up to date different healthcare records are. 3.1.2 Hospital staff described using a two-source checking process when a patient was admitted to hospital to determine an accurate history of their medications. For example, staff would check with the patient as well as checking against their GP records. This was described as being time consuming for staff as they would often have to check records in multiple places or speak to different people involved in a person’s care. While time consuming, it was said to be an essential step to ensure a patient’s safety. In the patient safety event, following the two-source checking process, it was confirmed that the patient had been taking metformin in tablet form. Care input from the diabetes specialist nursing team 3.1.3 The investigation learned that the diabetes specialist nurse (DSN) reviewed the patient soon after his admission. The DSN team received referrals from different wards across the hospital and supported patient care by carrying out diabetes medication reviews, providing education to patients and helping them to prepare for a safe discharge. 3.1.4 The DSN service was funded to run on weekdays only between 08:00 hours and 16:00 hours. Out of hours diabetes support was accessed via the medical team on call. Although it was not a specific factor in this case, the investigation heard that this often meant varying levels of diabetes specialist support was available during those times. Staff also explained that this increased the DSN team’s workload on Mondays as there would often be patients to see who had not been seen at the weekend as their medical need was deemed non-urgent. 3.1.5 It has been recognised nationally that healthcare staff who interact with people with diabetes do not always fully understand the care needed to keep them safe, and that trusts should work towards providing base-level specialist diabetes cover at weekends (Rayman and Kar, 2020). The Joint British Diabetes Societies for Inpatient Care (2023b) developed a staffing calculator which can help to determine suitable staffing levels. 3.1.6 In addition, changes to the patient catchment area and service provision for the hospital had increased the DSN team’s workload. Capacity challenges were exacerbated by a high prevalence of diabetes in the local population. The patient received input from the DSN team on two occasions during his inpatient stay. The investigation did not have evidence to suggest whether the capacity challenges had a direct impact on this patient’s care but acknowledges the wider implications this can have for patient care. Changes to medications 3.1.7 A decision was made on admission to prescribe the patient insulin to manage his diabetes. The decision to prescribe insulin was not explored as part of the investigation. 3.1.8 The patient was initially prescribed a type of long-acting insulin pen but this did not adequately control his blood glucose. Therefore, during his stay this was changed to a different type of combination insulin pen to be used twice a day. This was a combination of short and intermediate acting insulin which provided better control of his blood glucose. 3.1.9 While it was not possible to confirm definitively what happened to the patient’s medications, the investigation understands that the patient was discharged home with two different types of insulin pen in his belongings. Finding both pens when he arrived home added to his confusion about taking his insulin and he did not take any. 3.1.10 Staff told the investigation that when a patient’s medication regimen changed, medication that was no longer needed was placed in secure bins on the wards for return to the pharmacy. Staff acknowledged that a full check might not always be carried out of the patient’s lockable bedside cabinet or their personal belongings to remove any old medications. 3.1.11 The approach to checking for medications was described as being inconsistent, with staff not always having time to regularly check a patient’s belongings for old medications. An example of when this might not happen is what staff called a “lift and scoop”, where a patient and their belongings are moved to another ward or bed and their belongings, including medications, are taken as they are. There might not be time to do a full medication check before this, particularly if it happens during a busy time or if the patient move is urgent. Summary 3.1.12 The medication check for the patient ensured he was on the correct medication. This was despite conflicting information and the time taken to do a two-source check. There were capacity challenges for the DSN team due to changes in the patient catchment area and service provision for the hospital, but there was no evidence to suggest this directly affected the patient’s care. The DSN team saw the patient on two occasions during this stay. The patient’s diabetes medications were changed to insulin on his admission to hospital, and the type of insulin medication was changed during his stay. The evidence gathered during the investigation suggests the he was discharged from hospital with two types of insulin pen. Once at home, this added to his confusion about what he should take and he did not take any. 3.2 Planning for discharge in hospital Diabetes education 3.2.1 Three days before the patient was discharged, the DSN team spent time with him and his partner, providing diabetes education on his amended insulin regimen. This covered when to administer the insulin, the doses and how to use the blood glucose meter. How to adjust the insulin dose was discussed, as well as injection technique. The patient was given leaflets detailing injection technique and what to do if he became unwell. Booklets on type 2 diabetes and healthy eating were also provided. 3.2.2 There was no detail in the medical record of how it was checked that the patient had understood the information he had been given. Given the length of time that had elapsed since the event, staff could not recall this specifically for the patient. Staff described that usual practice involves asking patients to repeat back the information provided during any education given, to make sure they have fully understood it. 3.2.3 The investigation was told by pharmacy staff that if a patient has the capacity to understand instructions and carry out tasks they can be supported to self-administer with supervision. Supporting people to look after and take their own medications, unless a risk assessment suggests otherwise, has been highlighted as good practice by the Care Quality Commission (2019). The safe self-administration of medication was recognised as a challenge in the first in HSSIB’s series of investigations into medication-related harm (Health Services Safety Investigations Body, 2024). 3.2.4 Following the diabetes education, the patient was supported to self-administer while in hospital, for 3 days, in preparation for discharge. There was no detail within the medical records to confirm whether the patient was supervised during his self-administration or what checks were done to make sure he felt confident about self-administering after his time with the DSN team. Staff described that they would usually supervise a patient self-administering on several occasions to make sure they were able to do it correctly. 3.2.5 A key component to successfully teaching patients to self-administer insulin is focusing on ‘why’ they need to do this and the importance of it, as well as ‘what’ to do (Chin and Robins, 2019). There was no entry in the medical record to indicate whether the reason for taking insulin, and the importance of it, was conveyed fully to the patient. 3.2.6 The hospital trust have a policy in place for self-administration of medications but acknowledged that improvements were needed to support patients to safely self-administer medications as this was noted to be an area where it had had concerns. One of the local integrated care boards that commissions services in the area, was supporting the trust, along with other local trusts, as part of a wider piece of work to support patients to self-administer their medication during hospital stays. 3.2.7 The patient told the investigation that he felt confident in administering his medication until he got home. Once at home, he found two different types of insulin pen in his belongings and was confused about which he should use. It was unclear to the investigation what prevented the patient from seeking help and advice, or if his partner was aware of his confusion about his insulin medications. 3.2.8 The investigation learned that consideration was given to individual patients’ circumstances when providing insulin/diabetes education, so that they could be best supported in readiness for discharge, which was tailored to their needs. An example given was if a family member was with a patient during any diabetes education, but they did not live with the patient, staff would make sure that the patient felt confident to administer medication on their own. 3.2.9 It was not clarified in the patient’s medical records what role his partner would have in supporting the self-administration of insulin. Some patients may have complex family arrangements and therefore clarifying the role of family members or carers may assist in understanding the level of support a patient needs. Patient confusion 3.2.10 In the patient’s GP record after the safety event, it stated the patient ‘initially couldn’t remember to administer insulin’. The investigation explored how hospital staff assessed a patient’s capacity to understand information, and their ability to retain it. Staff described that on admission a medical assessment was undertaken which included a review of a patient’s capacity. 3.2.11 While a patient’s capacity would not be formally assessed again during the admission unless there was a specific need to, staff said that they would dynamically assess whether a patient was able to retain information sufficiently. This would be based on their clinical signs and symptoms. During any education, patients would be asked to repeat the instructions they had been given to show they had understood. HSSIB ( 2023 ) has previously reported on the challenges staff face in assessing patients’ capacity to consent to routine bedside tasks, as often the training staff received focused on major interventions such as surgery. In the safety event there was no formally documented assessment of the patient’s capacity or ability to understand and retain information. 3.2.12 The investigation acknowledges that a patient’s ability and confidence to self-administer while in the supportive environment of a hospital ward may differ from when they are at home. The investigation saw evidence that the challenges around self-administration of insulin and adherence to a new regimen were acknowledged by staff at the hospital, given that a follow-up call with the patient from the DSN team was planned for the week after discharge. HSSIB ( 2025b ) has also acknowledged this challenge and a wider piece of work is underway to explore how self-administration of medications in the community can be supported. The discharge lounge 3.2.13 A discharge lounge is a dedicated area within a hospital for patients who have been medically discharged but are still waiting for things such as medication or transport. The investigation was informed that the patient involved in the safety event was discharged via the hospital’s discharge lounge. The patients records included a discharge record, although staff could not recall any specific detail about the discharge given the length of time that had passed since the event. The discharge paperwork did not clearly show when the patient left the ward to go to the discharge lounge or whether discharge arrangements were made by the ward or the discharge lounge staff. The investigation therefore explored usual practice. 3.2.14 The discharge lounge at the hospital operated daily from 07:00 hours until 19:30 hours. Approximately 25 to 30 patients accessed the discharge lounge each day. 3.2.15 Safety meetings took place three times a day. A senior nurse led the meeting and nursing staff from different wards gave updates on possible discharges, admissions and any barriers to patients being discharged home. Since the patient safety event happened, many of the processes at the hospital have changed following a significant environmental change and staff described that the safety meetings have helped to manage patient flow effectively. 3.2.16 The discharge lounge team described how they played a role in “vetting everything” in the discharge lounge and that they “unblock barriers”. They had also recently employed a doctor to work in the discharge lounge and said this had helped to support safe discharge. This demonstrated the additional roles and responsibilities taken on within the discharge lounge; rather than providing a holding area for patients before they went home, there was more of a requirement to get involved in patient care and tasks such as medication checks. 3.2.17 The investigation saw the complexities involved in managing patients’ discharge from the discharge lounge. While the national discharge framework suggests a clear process to follow, in reality often this is more challenging for staff due to additional arrangements that might need to be made that are only identified once the patient is in the discharge lounge. 3.2.18 During the investigation’s observation of care, the discharge lounge team manager appeared to have oversight of care and the ability to support effective patient flow. Numerous staff told the investigation they would go to that person as a single point of contact for information and advice. 3.2.19 Staff described the standard process for a patient awaiting discharge from the discharge lounge. This included a review of medications against the discharge summary of medications, to make sure the patient had everything they needed. The investigation attempted to understand whether it would be identified in the discharge lounge if a patient had an additional medication in their belongings that they no longer needed. 3.2.20 Staff said they would normally check a patient’s medications in the discharge lounge before they went home. However, it was acknowledged that a patient could have additional medications in their own belongings that might not be checked, as staff would not routinely go through a patient’s personal belongings. An additional check at this point could provide a barrier to a patient accidentally going home with incorrect medication. 3.2.21 In the patient safety event, the investigation saw evidence of the steps within the discharge framework being followed with a discharge plan made for the patient, this being discussed with the patient and his partner, and arrangements for follow-up care being made. A discharge checklist was completed; this was in a yes/no/NA (not applicable) format with no supporting detail. There was no question in the checklist about whether all the medications the patient had had been checked. Questions related to medications were: ‘TTO [to take out] meds given to patient?