Medication related harm

We have launched three local investigations and one national investigation into medication related harm.

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.

We have identified the theme of medication related harm to patients from reviewing:

• patient safety concerns reported to HSSIB by the public
• serious incidents reported nationally
• Prevention of Future Deaths reports, issued by coroners
• previous investigation reports by the Healthcare Safety Investigation Branch (HSIB).

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.

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.

Local investigations

The three locality-based patient safety investigations, with actions aimed at specific NHS trusts, will each focus on a different area of the patient pathway, including a change in healthcare setting:

• Medications not given: Administration of time critical medications in emergency departments.
• Medications not given: Anticoagulation before and after a procedure.
• Medications not given: Patient discharge to nursing home care.

These investigations will be carried out at three different NHS trusts.

National investigation

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:

• The safe use of Electronic Prescribing and Administration Systems (ePMA) in acute hospitals.

This national investigation will start in spring 2025.

We are keen to hear from anybody with an interest in this subject matter, particularly if you are aware of an impact on patient safety. This includes patients, families, carers and health and care professionals who may wish to share their experience. If you would like to speak to us about these investigations, please email enquiries@hssib.org.uk.