How a communication error and subsequent medication mix up led to the death of a patient

Pharmacy In Practice Podcast

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.