What can we learn from this tragic fatal warfarin error?


Failure to identify high-risk medication errors in patients with complex needs can have a fatal outcome, a recently published report warned.


The report, published by Healthcare Safety Investigation Branch (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.


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 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.


In this podcast, we were fortunate to be joined by Lead Investigator Deinniol Owens. We discuss some of the pertinent points in the investigation and explore some of the wider questions about pharmacy. In particular, we discuss how this investigation makes the case for the integration of pharmaceutical care led by pharmacists into every multidisciplinary team in the country.




You can read the full report here.


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PIP editor

A pharmacist led training provider.

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