• Skip to main content
  • Skip to primary sidebar
  • Home
  • News
  • Events
  • Education
  • Interviews
    • Career spotlight
  • Opinion
    • Professional Dilemmas
    • Patient perspective
  • PIPcast
  • Jobs
  • Business Directory

Pharmacy in Practice

EDX/20/1154
Date of prep: December 2020

Prescribing information and
adverse events reporting

For healthcare professionals only

Spotlight on hospital pharmacy after fatal warfarin error

24th September 2020 by PIP editor Leave a Comment

 

Failure to identify high-risk medication errors in patients with complex needs can have a fatal outcome, a new report warns today.

 

The report, published by HSIB, sets out a case where a medication error with warfarin contributed to the death of a 79-year-old man.

 

The patient had suffered a fall at home and had been admitted to hospital. An error on his chart whilst he was on the ward led to him receiving three or four doses of warfarin, which he did not normally take before the error was spotted by a ward-based clinical pharmacist. The patient developed internal bleeding and deteriorated (due to several health reasons) and died 21 days after his first admission.

 

The report highlights the growing ageing population and that pharmaceutical care of older people can be complex. They are often taking multiple medications and are at the greatest risk of harm due to medicine-related errors. In the case HSIB examined, the patient was on 12 different medications and supplements at the time of admission. By day nine of his hospital stay, this had increased to 16.

 

HSIB’s national investigation focused on the role of ward-based clinical pharmacy services and how they work within the multidisciplinary teams (MDT’s) that administer care to patients. Ward-based pharmacists are crucial in enhancing the team’s ability to spot errors, especially in high-risk situations. However, the investigation findings emphasised that there is variance in the way the services are staffed and organised.

 

They also found that other staff within the MDT’s could better understand the role pharmacists have in between admission and discharge of the patient. HSIB also found that more work needs to be done to assess the resilience of pharmacy services to operational pressures and the additional challenges associated with caring for older people.

 

As a result of the national investigation, HSIB has made three recommendations to facilitate a better understanding of the role of the ward-based pharmacist and to encourage best practice and resilience when identifying and developing models of pharmacy provision.

 

Safety recommendations as a result of this investigation include the following:

 

  • 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.
  • 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.
  • 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.

 

Safety observations in this case include the following:

 

  • 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 int 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.

 

Dr Stephen Drage, HSIB’s Director of Investigations and ICU consultant said:

 

“Medication errors are one of the most frequent failures of care and it can have a devastating outcome, as sadly shown by the case that launched our investigation.

 

“Through our investigation, it emerged that collaboration within MDT’s is key. Better understanding the role of the ward-based pharmacist and the expertise they bring can help reduce medication errors, especially in high-risk situations.

 

“The safety recommendations set out in the report focus on ensuring a national approach to modelling pharmacy services, giving trusts the best chance to increase their healthcare resilience. This is now more important than ever as the NHS tackles Covid-19 and the extra pressure the pandemic is putting on services.

 

“Medication errors are more likely to occur when patients are older or have complex needs, but they can impact any patient. Increasing the efficiency and effectiveness of pharmacy services can help to reduce the risk of error and ensure consistency of care for all.”

 

You can read the full report here.

 

Have your say by writing to the editor. Do hospital pharmacy services need to be reformed?

 

We'll use your email address only to get back in touch with you after filling in this form.
We welcome all contributions and personal opinions are encouraged but please do make sure you back up any claims with suitable references.

 

 

 

 

Share this:

  • Click to share on LinkedIn (Opens in new window)
  • Click to share on Facebook (Opens in new window)
  • Click to share on Twitter (Opens in new window)
  • Click to share on WhatsApp (Opens in new window)
  • Click to share on Telegram (Opens in new window)
  • Click to email this to a friend (Opens in new window)

Related

Next article  GPhC publish new pharmacist education and training standards

Filed Under: Featured, News Tagged With: Error, Human factors, Oral anticoagulants

Register for our upcoming webinar and live Q&A

About PIP editor

Pharmacy in Practice is a UK pharmacy publication with its roots in Scotland.

Reader Interactions

Begin the discussion right here Cancel reply

Primary Sidebar

Categories

Follow Us

  • Twitter
  • LinkedIn
  • Facebook
  • Instagram
  • Twitter

PIP business directory

Letters to the editor

Letters to the editor

Provisionally registered pharmacists should not have to sit the exam

Community pharmacists can identify high-risk asthmatic patients

No national Scottish pharmacy flu service a missed opportunity

Admiration for community pharmacy in Scotland

More letters to the editor here...

Blogs

💊 PIP live pharmacy blog

Winter stresses must not ‘destabilise’ general practice

What is it like to depend on medicine to treat endometriosis?

Opinion

Why is pharmacy not integral to government mass vaccination plans?

Pharmacy Covid-19 vaccination involvement is a ‘no-brainer’

The great patient medication returns debacle

CPD Challenges

💊 CPD Challenge: How well do you understand pulmonary embolisms?

💊 CPD Challenge: Prescribing and dispensing clozapine

💊 CPD Challenge: Oral anticoagulants – Dabigatran

More CPD challenges here...

© 2021 · About Pharmacy In Practice · Site mantained by Mike

This site is for healthcare professionals, please confirm you are a healthcare professional to continue.

YES

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
Pharmacy In Practice uses cookies, by continuing to use this site we will assume you are ok with that Find out more.