This is the second in a series of investigations exploring patient safety events that took place in NHS organisations to understand the local factors that may contribute to patients not receiving medications as planned.
It looks at the systems and processes in place to support staff in identifying the need for, and making decisions about, the prescribing and administering of anticoagulant medication before and after a procedure. It also explores the role of electronic patient record (EPR) and electronic prescribing and medicines administration (ePMA) systems in supporting care in this area.
Patient safety event
The 87-year-old man involved in the patient safety event usually took an anticoagulant medication to reduce his risk of stroke. He was admitted to hospital where he stayed for 14 days, during which time he underwent a chest procedure. His anticoagulation medication was paused on the day he was admitted and not restarted after the procedure. Key medical information that the clinical team needed to be aware of was not readily accessible from either the GP or hospital records.
We investigated the factors that may have led to his medication not being restarted. As the report demonstrates, there were a range of complex, dynamic and interacting clinical and organisational factors at play. These included:
- Bed capacity and decision making about transferring the patient to a respiratory ward.
- The time the patient was off anticoagulant medication before his procedure.
- Prioritisation of the patient’s CT scan.
- Prompts for staff to restart anticoagulation after a procedure.
- The information available to staff in local guidance.
Learning prompts for hospitals
The report outlines local-level learning prompts for acute NHS hospital trusts, to help to improve the safety of patients who are taking anticoagulation medication who need to have a procedure.
The prompts focus on:
- anticoagulation prescribing
- care processes supporting inpatients on anticoagulants
- EPR/ePMA systems supporting anticoagulation.
Importance of a systems view
Clare Crowley, Senior Safety Investigator at HSSIB, says: “Decision making around medication is highly complex and dynamic, so needs to be frequently revisited to ensure that the decision remains the most appropriate.
"The patient safety event described in the report reflects the everyday challenges in care provision. It demonstrates why a systems view needs to be taken and that solely looking at medication aspects is inadequate.
"We strongly urge that acute hospital teams review the learning prompts in the report to help to improve patient safety in this area.”
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