A recent investigation by the HSIB identified the potential for technology-related medication dosing errors with ePMA systems


Electronic prescribing and medicines administration (ePMA) systems continue to be rolled out across hospital trusts as part of the NHS’s plan to eliminate paper prescribing in hospitals and introduce digital prescribing across the NHS by 2024.

Figures provided by NHSX show that around 50% of trusts are currently using ePMA systems, with a further 25–30% funded for go-live dates over the next 12–18 months following roll-out delays due to the COVID-19 pandemic.

However, a recent national investigation by the Healthcare Safety Investigation Branch (HSIB) has raised concerns that they are not as safe as commonly believed, and have the capacity to cause technology-related medication dosing errors, particularly in paediatric services.

Proposed benefits of ePMA systems

There are an estimated 237 million medication errors per year in the NHS in England, 66 million of which are potentially clinically significant. These errors are estimated to cost the NHS at least £98 million and contribute to the loss of more than 1700 lives annually, according to a study published in BMJ Quality & Safety.

NHS England maintains that increased uptake of ePMA systems by trusts will correspond to a 30% reduction in medication errors compared with traditional methods, and a similar reduction in adverse drug events.

ePMA systems may also enhance patient safety by ensuring that critical information is provided in a timely way, and will allow automation of some processes, increasing efficiency while reducing the risk of error. Medication reviews can be more easily undertaken, and prescriptions automatically linked to discharge letters.

The use of ePMA systems has been shown to save time and money by reducing unnecessary bureaucracy and freeing up clinician time—instead of relying on sometimes unintelligible handwritten notes and paper medicine charts, healthcare staff can quickly access crucial information across a range of sites and technical devices.

A spokesperson for NHS Digital told Medscape UK, ‘[ePMA systems] can facilitate improved patient safety by, for example, alerting the prescriber of a drug allergy or interaction. They also allow organisations to understand prescribing habits and ensure good medicines management.’ 

Mass recording of data 

Mass recording of data is another key benefit of ePMA systems, enabling the monitoring of hospital- and trust-level prescription trends, and allowing them to be checked against patient outcomes. The data can also be linked to other datasets to provide new insights and support medical research, enabling evidence-based policy decisions.

Since December 2020, NHS Digital has established a daily collection of data relating to medicines prescribed and administered to patients from secondary care NHS trusts with ePMA systems in England. In April 2021, it announced that these data were being made available to support COVID-19 research, and that it was expanding the number of ePMA systems that would provide this information (there are a number of different ePMA system providers operating in the UK market).

Speaking at the time, Ann Slee, Associate Chief Clinical Information Officer (Medicines) at NHSX, said: ‘This is a huge step forward, and forms the basis for the longer-term national collection of ePMA data that will support numerous medication safety and other overprescribing initiatives.

‘It will help us to further develop the right standards to underpin hospital prescribing, and deepen our understanding of and approach to managing challenges such as antimicrobial resistance.’

Safety issues 

Although one of the main reasons for implementing ePMA systems is reducing medication errors, the findings of a recent systematic review and meta-analysis concluded that their impact on the rate of medication errors is actually variable.

‘Despite the wide-scale adoption of [electronic medication systems] in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks’, the study said.

And although research has shown that ePMA systems reduce errors associated with legibility and transcription, they can also create new types of error rather than eliminate error burden, as there is a lack of standardisation in their use in the UK.

NHS Digital has acknowledged that ‘it must be recognised that failure, design flaws, or incorrect use of such systems have the potential to cause harm to those patients that the system is intended to benefit’.

Tenfold errors 

Prescribing errors are the most frequent type of medication error in paediatric inpatient healthcare settings. Prescribing for children is complex because prescriptions must be individually tailored based on factors such as weight, age, gestational stage, and body surface area. One of the biggest concerns with ePMA systems is the potential for ‘tenfold’ errors, especially in paediatric services.

As previously reported, the HSIB recently conducted a national investigation into weight-based medication errors in children, triggered by a case of unintentional tenfold overdose in a 4-year-old child.

An anticoagulant for the reference case child was prescribed by a junior doctor using the hospital’s ePMA system. Although the clinician had correctly interpreted the dose from the guiding formularies, the prescribing pathway led to the administration of the tenfold overdose on five separate occasions before it was identified.

As part of its wider investigation, the HSIB found that there are no standards for what safety-critical functionality should be available in ePMA systems used in paediatrics (for example, the use of weight-based dose bands, where individually calculated doses are rounded to a set of predefined doses).

‘Also, local configuration of ePMA systems potentially introduces variability and risks if not undertaken with clear understanding of the potential hazards and their mitigations. The issue of configuration was a key issue in this investigation and the previous one published in 2019’, the HSIB said.

The findings of this investigation suggest that there is a need for increased awareness among the medical community about the limitations of ePMA systems. An HSIB spokesperson told Medscape UK‘We found that clinicians perceived the ePMA system would be capable of “catching” their errors, so causing an over-reliance on the system. Other clinicians viewed the ePMA system as an electronic version of the paper chart, and expected the prescribing functionality would be similar, which was clearly not the case. The issue of workarounds has been highlighted to us too, both in this investigation and a previous one, which then requires re-training of staff, system modifications, and so on.’

Switching between electronic and paper prescribing is a significant safety risk

The 2019 HSIB report identified a significant safety risk, spanning primary and secondary care, regarding the prescribing of high-risk medications using both electronic and paper systems.

The reference event involved a 75-year old woman with terminal cancer who was left taking two powerful anticoagulants at the same time after being discharged from her local hospital.

This investigation highlighted that incomplete use of ePMA systems may create further risks to patient safety. The HSIB made four safety recommendations to NHSX, one to the DHSC, and one to NHS England and NHS Improvement as a result of this investigation.

An HSIB spokesperson told Medscape UK: ‘From this investigation, we found that there was limited knowledge and data relating to unintended consequences of introducing ePMA systems because of the varied nature of health [information technology] IT products and the lack of common criteria against which to measure the impact. We also found that commercial ePMA systems reduced medication errors if the available functionality was switched on, used appropriately, integrated with other relevant IT systems, and aligned with clinical workflows.’

They added that the implementation of their recommendations from both investigations should enhance the safety of ePMA systems.

Going forward

As the roll-out of ePMA systems continues apace across NHS trusts, there are number of factors that are crucial to their successful adoption and to maximising patient safety.

An expert on the roll-out of ePMA systems in England, Ramandeep Kaur (Lead ePMA Pharmacist at Barking, Havering, and Redbridge University Hospitals NHS Trust), said that careful preplanning and stakeholder engagement—‘making sure that everybody is on board from the outset’—is key to the successful implementation of any ePMA system. Furthermore, providing adequate training of all relevant staff before roll-out and having all the necessary resources in place are also vital, as switching to an ePMA system is ‘a massive, complex, transformational change’.

‘I think one of the shortcomings often in organisations is not necessarily having the right resources, both from the implementation perspective and post-implementation perspective, so it is business as usual’, she said, adding that ‘flexibility and agility’ are also important on the part of trusts, clinicians, and ePMA system suppliers to enable adaptation to changing needs and improvement of any identified shortcomings.

Kaur noted that there are over 20 suppliers of ePMA systems operating in the UK market, with a lot of variety, so interoperability with other systems is crucial.

Furthermore, whatever their functionality, Kaur stressed that ePMA systems cannot replace human interaction. ‘You still need to be able to go out and speak to your patient and, fundamentally, in all the years I’ve been doing this, I’d still advocate the importance of speaking to the patient, speaking to the clinician, being out on the “shop floor” as it were, to have those conversations and not solely rely on the system. Because with these systems you can have certain levels of clinical decision support and system alerts, but you can end up with alert fatigue… so people can end up ignoring those flags.’

Kaur concluded by saying that the main benefits of ePMA systems ‘are qualitative, and about doing what is right for our patients.’

This article originally appeared on Medscape,  part of the Medscape Professional Network.


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