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Medication safety

Ward-based pharmacy services help reduce high-risk prescribing errors in hospitals, report concludes

An investigation by the Healthcare Safety Investigation Branch concluded that ward-based pharmacy services can play an important role in identifying and reducing high-risk medication errors in hospitals.

warfarin tablets


The Healthcare Safety Investigation Branch report identified incidents relating to the incorrect prescribing of warfarin through ongoing monitoring of NHS systems

Ward-based pharmacy services can play an important role in helping multidisciplinary teams identify and reduce high-risk medication errors in hospitals, a report from the Healthcare Safety Investigation Branch (HSIB) has revealed.

However, the report also noted significant variation in how ward-based pharmacy services are staffed, organised and developed across England.

The HSIB — a government-funded body that conducts independent investigations of patient safety concerns in NHS care settings across England — aimed to investigate the role of hospital pharmacy services in helping to identify and reduce high-risk prescribing errors in NHS trusts. Investigators defined high-risk medicines as those that risk significant patient harm or death when used in error.

The report said that the HSIB had identified incidents relating to the incorrect prescribing of warfarin through ongoing monitoring of the NHS national incident reporting and learning system, and the strategic executive information system. These incidents, it said, highlighted the “complexity” associated with prescribing and administering medicines.

The investigation concluded that “ward-based clinical pharmacy services can play an important role in helping the multidisciplinary team to identify and reduce high-risk medication errors”.

However, they found that there was not a consistent, shared understanding between NHS staff of medications that may be considered high-risk, or situations in which there is a higher risk of medication errors occurring.

There also appeared to be “significant variation in the organisation and understanding of the role of ward-based clinical pharmacy services in the NHS between the point of initial medicines reconciliation and discharge”, the report said.

The investigators added that “there may be a gap between the expected standard of pharmacy care and the care pharmacy services are actually able to deliver within the constraints of current systems and pressures”.

Roisin O’Hare, president of the Guild of Healthcare Pharmacists, said that pharmacy teams, and other healthcare professionals providing pharmaceutical care, should be encouraged “to audit their service provision in order to identify gaps, and to invest in pharmacy services to ensure that patients are kept safe at every stage of their hospital admission and beyond into primary care”.

“We must recognise that ward based clinical pharmacy services are not a luxury, and require equitable investment to operational and technical services within the pharmacy department,” she said

The report made several recommendations, one of which was for the Royal Pharmaceutical Society (RPS), supported by NHS England and NHS Improvement, to provide guidance on models of hospital pharmacy provision, including information on the models’ ability to enhance safety and healthcare resilience, and consideration of the appropriate skill mix and experience within the hospital pharmacy team.

Robbie Turner, director of pharmacy and member experience at the RPS, said that, through its hospital expert advisory group, the RPS had been supporting the HSIB with the investigation and therefore welcomed the report.

“We are mindful clinical pharmacy services save lives but also aware there is variability in how these operate,” he said.

“It’s important for clinical pharmacy services to be clearly defined and models of hospital clinical pharmacy provision to be developed so more people and the NHS can benefit from them.

“The RPS hospital expert advisory group have the expertise to support this work and the RPS looks forward to undertaking work in this area.”

The report also recommended that the NHS specialist pharmacy service should update its resource on the prioritisation of hospital 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.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2020.20208388

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