The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital
HSIB Legacy
Published
Medication
Communication and decision making
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.
3 recommendations
4 observations
1 of 3 responded
Safety Recommendations (3)
NHS England
R/2020/087
It is recommended that NHS England and NHS Improvement carry out work to understand and further define the work of hospital clinical pharmacy teams, including the period between initial medicine reconciliation and discharge, in consultation with relevant stakeholders.
NHS Specialist Pharmacy Service
R/2020/089
It is recommended that the NHS Specialist Pharmacy Service should update its resource on the prioritisation of hospital clinical pharmacy services to facilitate the dissemination of developments in good practice and policy with respect to pharmacy prioritisation and the issues highlighted in this report.
Royal Pharmaceutical Society
R/2020/088
It is recommended that the Royal Pharmaceutical Society, supported by NHS England and NHS Improvement, should provide guidance on models of hospital clinical pharmacy provision. The guidance should provide information on the models’ ability to enhance safety and healthcare resilience and include consideration of the appropriate skill mix and experience within the clinical pharmacy team.
The Royal Pharmaceutical Society will develop professional guidance on models of hospital clinical pharmacy provision to define their work, aiming to reduce variability and underpin patient safety.
The Royal Pharmaceutical Society welcomes HSIB’s report. We are the professional body for pharmacy with a mission to put pharmacy at the forefront of healthcare, and our vision is to be the world leader in the safe and effective use of medicines. Through our Hospital Expert Advisory Group we will work with the NHS to support the recommendations made, which we believe will reduce variability and underpin patient safety. Clinical Ward pharmacy is an important part of the "safety net" in operation in hospital. In addition to improved understanding, definition and guidance on models of care, it is important to instil a culture where everyone constantly questions the medicines that are being prescribed and administered, and the reasons why. We will develop professional guidance on models of hospital clinical pharmacy provision, to define the work of hospital clinical pharmacy teams. Response received on 16 December 2020.
Safety Observations (4)
Effective clinical pharmacy services have been evidenced to improve a range of measures linked to efficiency and patient safety in acute hospitals.
Further integration of clinical pharmacy services within the MDT and within strategic decision making may improve a shared understanding of which medicines and situations place patients at greater risk of serious medication errors occurring.
Clinical pharmacy services should consider using validated tools to assist in prioritising pharmacy care and identifying high-risk medicines and high-risk situations for medication error. Where electronic medical record systems are used, such tools could be integrated into these systems to aid prioritisation.
Caring for older patients in hospital often presents a high-risk situation for medication errors occurring. Further efforts should be made to learn from technological developments and the organisation of pharmacy services in other high-risk areas of care that may improve system resilience in older persons care.