We have launched three local investigations and one national investigation into medication related harm. To date we have published two investigation reports:
Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. This can include an irreversible deterioration in symptoms that the medication was controlling and death.
These investigations explore the safety issues associated with medication not given. HSSIB was told of many instances where patients do not receive the medication they need whilst in hospital, at home or in a nursing home.
With advances in technology most NHS hospitals now have an electronic prescribing and medicines administration (ePMA) system. These systems have been shown to reduce some medication errors. However, ePMA systems can introduce different errors if they are not well understood and do not support staff in the task of prescribing and administering medicines. The way ePMA systems are used varies both within and between hospitals which can cause problems for staff.
HSSIB will undertake three local investigations in relation to medication not given across the healthcare pathway and one national investigation in relation to the safe use of ePMA systems in the hospital setting.
The three locality-based patient safety investigations, with actions aimed at specific NHS trusts, each focus on a different area of the patient pathway, including a change in healthcare setting. These investigations will be carried out at three different NHS trusts.
Completed investigations:
Ongoing investigations:
The local investigations will examine the specific ePMA system in use and the findings will be used, alongside learning from previously completed HSSIB investigations, to inform a subsequent national investigation:
This national investigation will start in spring 2025.
We have identified the theme of medication related harm to patients from reviewing:
This highlighted patient safety risks with medication not being given to a patient across the healthcare pathway and issues with ePMA systems in the hospital setting.
Additional intelligence has been gathered by exploring these topics with 15 experts with knowledge in medication safety from national organisations and academia.
Medication not given: administration of time critical medication in the emergency department