Source · HSSIB Patient Safety Investigation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Published 28 May 2026
Published
Medication
Communication and decision making
Continuity of care
This is the fourth investigation looking at medication related harm, exploring the safety issues associated with medication not given. Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. This can include an irreversible deterioration in symptoms that the medication was controlling and death.
Summary
5 recommendations
3 observations
Safety Recommendations
R/2026/086
Medicines and Healthcare products Regulatory Agency
HSSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures that:
routes for manufacturers and healthcare organisations to engage with them are clear and accessible
it reviews and provides further guidance and clarification on when electronic prescribing and medicines administration (ePMA) software should be considered a medical device.
This will support how ePMA software can be appropriately classified and regulated to improve patient safety.
No response published on HSSIB's website
R/2026/087
NHS England/Department of Health and Social Care
HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in the safety of ePMA functionality.
No response published on HSSIB's website
R/2026/088
NHS England/Department of Health and Social Care
HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance processes.
No response published on HSSIB's website
R/2026/089
NHS England/Department of Health and Social Care provides additional support to acute hospital trusts
HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to:
supporting healthcare providers to access digital clinical safety knowledge, capacity and capability
integrating digital clinical safety and patient safety, including the associated terminology
supporting robust assurance of whether electronic prescribing and medicines administration (ePMA) manufacturers comply with relevant standards in order to be considered for inclusion on an NHS procurement framework.
This will support effective decision making and oversight by acute hospital trusts and reduce unwarranted variation in the understanding of, and approach to, adopting ePMA.
No response published on HSSIB's website
R/2026/090
CQC
HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to ensure oversight of ePMA functionality to improve patient safety.
No response published on HSSIB's website
Safety Observations
Observation 1
Observation
Commercial manufacturers can improve patient safety by applying the standards and expectations for a medical device when developing electronic prescribing and medicines administration (ePMA) functionality, to help provide further assurance to acute hospital trusts procuring or updating ePMA functionality.
Observation 2
Observation
Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums.
Observation 3
Observation
Commercial manufacturers and NHS organisations can improve patient safety by contributing to and engaging with ePRaSE (ePrescribing Risk and Safety Evaluation) processes to support ongoing improvement and optimisation of electronic prescribing and medicines administration (ePMA) functionality across the NHS.