Spotlight on hospital pharmacy after fatal warfarin error


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?






Why is it still a criminal offence if you make an inadvertent dispensing error?

Greg Lawton


Greg Lawton is a pharmacist specialising in patient and medicines safety, staffing, data protection, privacy and healthcare policy.


We were lucky to catch up with Greg to have an in-depth conversation about dispensing errors in pharmacy.


There a few things that strike fear into hearts of pharmacists more than making a dispensing error. Making a dispensing error is still a criminal offence and can still lead to a custodial sentence. Unfortunately, we live in the real world and these errors do on occasion happen.


Are there too many errors?

Are all near misses and dispensing errors reported and are they analysed appropriately?

Should pharmacists face potential custodial sentences?

Do we share insights nationally well enough?


The issue is still on-going but it is my hope that we re-ignite the conversation around this topic.



If you prefer to never miss an episode you can subscribe on your preferred podcast platform. Just click on the links below to get going.


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Medication error leads to investigation into electronic medication systems


Poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors, a new report has warned.


The report comes after the Healthcare Safety Investigation Branch (HSIB) looked at the case of 75-year old Ann Midson, who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer.


Ann sadly died from her cancer 18 days after being discharged and the error with her medication was only picked up three days before. This led to the HSIB investigation to question why this happened, even when the hospital had an ePMA system in place.


The report highlights that many NHS trusts across England are taking up this technology as they reduce medication errors, but that incomplete use of e-systems could create further risks to patient safety. The investigation found that often all the functions of ePMA systems aren’t being used and that staff switch between using paper record and digital records, increasing the likelihood of crucial information being missed.


Ann’s case also highlighted the routine lack of information sharing between NHS services, such as GP surgeries and pharmacies. She had been taking one blood-thinning medication on admission. This was stopped during her time at the hospital, but this message was not relayed to her local pharmacy and she continued to take both after leaving hospital.


The report also identifies that the availability of a seven-day hospital pharmacy service is crucial to support a digital system and pick up any errors quickly. The length of time it took in Ann’s case had a huge effect on both her and her family. Ann’s daughter said: “Not only were we grieving the loss of mum but also that she had to deal with the stress and upset of this towards the end of her life. She had to spend a lot of time within different parts of the NHS and all we ever wanted was for her to get the best possible care at every stage.


“I am glad HSIB decided to investigate this topic using mum’s case – it was reassuring to know that her experiences wouldn’t be lost, and her story would be told. Knowing that this may prevent similar incidents happening to other families is the best legacy for my wonderful mum to leave and what she would have wanted.” The report sets out several recommendations around better information sharing and communication, improving medication messaging and alerts to ensure the safe discharge of patients.


Dr Stephen Drage, Director of Investigations at HSIB and an ICU consultant says:


“ePMA systems are a positive step for the NHS – research shows if implemented well they can reduce medication errors by 50%. Our report is highlighting the risks if e-prescribing is not fully integrated and doesn’t create the whole picture of the patient’s medication needs from when they arrive to when they return home. The more efficient the system, the better the communication is with the patients, families and NHS services.


“We recognise the challenges the NHS faces in implementing e-prescribing, but we also know how terrible the experience was for both Ann and her family. The safety recommendations we’ve made are asking for national bodies to provide trusts with a blueprint for what a good system and implementation should look like. This will mean ePMA systems are used to their full benefit, reducing the risk of serious harm to patients.”



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