We recently ran a story about a new report that highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors.
We were very fortunate to catch up with Scott Hislop and Helen Jones, two of the investigators, on the podcast to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
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 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.
Daniel Greenwood on emerging roles for pharmacists working in emergency departments
In conversation with the Chief Pharmaceutical Officer of Scotland Rose-Marie Parr
Hemant Patel on pharmacists doing everything except surgery
Meet the author: Cathy Geeson describes the relevance of the newly developed MOAT tool in practice
Claire Thompson on being a leading woman in science
Ian Rudd on the new "Scottish pharmacotherapy service" and pharmacy in the Highlands
Emma Davies on bullying in pharmacy, Brexit and Johnny's lack of leadership training
Gregory Lawton on pharmacy technicians yesterday, today and tomorrow
PDA reveal early plans for outcome based community pharmacy pilot in Dudley
Podcast: CwPAMS - A unique project to fight back global antimicrobial resistance
Professor Zaheer-Ud-Din Babar - How to write a pharmacy encyclopaedia
Dr Lawrence 'LB' Brown - What is pharmacy like in America?
Cathrine Edgeworth talks consultant pharmacists, aesthetics and CRPS
Podcast: Mark Pitt - What is the point of the Pharmacist Defence Association Union?
Podcast: Philip Galt on the opportunities for Scottish community pharmacy
Risk, dispensing errors, pharmacy and what we can learn from aviation
New Scottish community pharmacist independent prescribing course
Podcast: What is it like to be a pre-registration pharmacist in Scotland?
Pharmacy manager Amanda Smith describes knife attack
Podcast: Hospital pharmacy, non-clinical pharmacist snowflakes and bullying
Create your
podcast in
minutes
It is Free
Good Mood Revolution
The Relaxback UK Show
On Call With Dr. Anselm Anyoha
Precision Medicine Forum Podcast
The Doctor’s Farmacy with Mark Hyman, M.D.
The Peter Attia Drive