Electronic prescription error lead to woman’s death, coroner finds
- 15 January 2020
A woman died after a mix-up with an electronic prescription caused her to continue taking the wrong medication for an infection, a coroner has found.
David Urpeth, assistant coroner for South Yorkshire West, said “there is a risk that future deaths will occur unless action is taken”.
Sandra Dawne Scott was prescribed the drug trimethoprim for a urine infection by clinicians at Royal Hallamshire Hospital.
On the same day, 18 April 2019, her GP saw the results of an earlier urine test she had taken that showed an infection that would not have responded to trimethoprim, and was instead prescribed amoxycillin.
The prescription was issued electronically for Scott to pick up at a nominated pharmacy.
Shortly after her appointment, the GP amended the system to ensure future prescriptions would not automatically be sent to the pharmacist. But unknown to the GP, the change meant the prescription for amoxycillin would not be available to download by the pharmacist.
Instead, the only prescription available was the script for trimethoprim.
The results of the urine test taken at the hospital were available on 20 April 2019 but were not acted upon.
Scott was admitted to Royal Hallamshire Hospital with worsening symptoms on 22 April. Her medication was amended and she was treated appropriately from this point, but she continued to deteriorate and died on 23 April.
The coroner that undertook an inquest into the death also found the GP’s colleagues were unaware of the “peculiarity” of the e-prescribing system, therefore other medical professionals were likely to be unaware of the issue.
Urpeth ruled that the patient would not have died if she had received the medication prescribed by the GP, or indicated by the hospital’s test results.
A copy of the report was sent to the GP practice, the hospital, NHS Digital chief executive Sarah Wilkinson and the clinical commissioning group (CCG) chief executive for response by 2 January, detailing action taken or proposed to be taken.
“In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action,” Urpeth said.
NHS Digital told Digital Health News they had been granted an extension until 30 January to reply to the report.
A spokeswoman said they were unable to comment on an ongoing matter.
‘Significant safety risk’ with e-prescribing
The Healthcare Safety Investigation Branch (HSIB) has previously identified a “significant safety risk” with electronic prescribing, following the death of a patient after being inadvertently given two types of blood-thinning medications at the same time.
The report published in October 2019, Investigation into electronic prescribing and medicines administration systems and safe discharge, highlighted a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge.
Ann Midson, 75, died after being prescribed two types of blood thinning medications. Clinicians changed her medication in hospital, but her pharmacy continued to prescribe a different medication as the system hadn’t updated her details.
Dr Stephen Drage, director of investigations at HSIB, said at the time: “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 between NHS services.
“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.”
10 Comments
This is a tragic story but 2 things spring to mind 1) I’m pretty sure EPS has prevented many tragedies associated with paper prescribing 2) Is there an early After Action Review outcome that could be shared across the CCIO and CIO networks? Its not a sin to make a make a mistake but it is a sin not to learn from it.
The design of the erroneously named EPS – The original name ETP (the electronic transmission of prescriptions) was a much more accurate description – was laid down in the 1990s (I was heavily involved) before most people had Internet access, broadband and way before the smartphone. The service needs a major redesign to take full advantage of modern technology and the lessons from digital commerce of the last 20 years.
fair enough, I have empathy, you can not put a price on a human life, but let us start to be honest, technical is as important as clinical within (y)OUR NHS,, EPS is probably saving tax payers 100’s of £ millions, and yes, lots of lives, such is the power of technical – cultural change from NHS leadership ? a recognition by y(OUR) NHS clinical leaders that that is the case … and strength from (y)OUR NHS non clinical leaders that that is NOW the truth – I am listening even if no one else is
If a px is signed and has a nominated pharmacy then it goes directly to that pharmacy. Any change after signing does not change this…the only way is for the pharmacist to return to the spine, cancel on receipt or the surgery cancel before the px is marked as dispenced on the pharmacy system.
No Abey
If the nomination is changed
And the prescription is sent via ePS
And then the nomination is changed back to the usual (home) pharmacy BEFORE the electronic prescription is downloaded by the intended pharmacy
Then the script is re-routed to the usual/home pharmacy
Which is what happened here
If a rx is sent via eps2 and then nomination changed it doesn’t affect the Rx that has been sent if it has been already dowbloaded. This will remain with the pharmacy until it is returned to the spine by that pharmacy. Some pharmacy systems now automatically download from the spine periodically, or pharmacy teams trained to download frequently mindful of acute Rxs (these systems don’t allow for marking of acute Rxs – another failure of the systems)
What I gather that has happened here is that the nomination to the pharmacy was cancelled after the first rx of trimethoprim and the amoxicillin rx never was recieved where it was intended.
I am confused, it is good this is being discussed in public, complete transparency is critical: 1. was the change to the elected dispensing pharmacy ? 2. these systems should be real time, in the cloud, the phrase “download” scares me 3. what is meant by script ? (is it the prescription digitised into a script ?). Please answer with clarity. There must be functionality for the prescriber to “stop” a prescription from being dispensed, That is just common sense …
https://www.emisnow.com/csm?id=kb_article&sys_id=d11faa041b98c0506062620e6e4bcb4a#46018_headline_changes
though doesn’t appear to be live yet
Whilst there are multiple issues here, not just the cancellation of the ePS by the GP (inadvertently), such as no safety netting/follow-up etc, certainly EMIS are introducing “one off pharmacy” nomination for just such a situation, whereby an electronic prescription can be sent to any chemist electronically (e.g. if patient is on holiday somewhere in England) without it affecting the patient’s usual nomination.
Not just EMIS that are implementing this – the one-off nomination function is an outcome of EPS version 4. Roll out is planned but dates for each practice/system still TBC. Can’t come soon enough to give some additional functionality to the system
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