Source · HSSIB Patient Safety Investigation

Medication not given: administration of time critical medication in the emergency department

Published 5 December 2024 Published

Medication Communication and decision making Continuity of care

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. These investigations explore the safety issues associated with medication not given. HSSIB was told of many instances where patients do not …

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Summary

1 observation 18 learning prompts

Safety Observations

1 total

Observation 1 Observation NHS trusts can improve patient safety by using the information contained in the information pack for the Royal College of Emergency Medicine’s Quality Improvement Programme on time critical medications to assess their preparedness and make local improvements in identifying, prescribing, and administering time critical medications in emergency departments.

Learning Prompts

18 total

Prompt 1 Learning prompt How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED?

Prompt 2 Learning prompt Who in your patient pathway is responsible for identifying patients who need time critical medications?

Prompt 3 Learning prompt Who in your patient pathway is responsible for prescribing time critical medications?

Prompt 4 Learning prompt How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed?

Prompt 5 Learning prompt What aids or tools are available in your organisation to help staff to identify patients who need time critical medications?

Prompt 6 Learning prompt What pharmacy support is available to staff in ED to support in the care of patients who need time critical medications?

Prompt 7 Learning prompt The first eight doses were not prescribed during the patient’s first 24 hours in the ED. The patient self-administered the first four doses.

Prompt 8 Learning prompt When the medication was prescribed, the morning dose was incorrect.

Prompt 9 Learning prompt A dose was prescribed but not given on day 3.

Prompt 10 Learning prompt How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?

Prompt 11 Learning prompt How does your organisation support patients to self-administer time critical medications, when appropriate?

Prompt 12 Learning prompt How does your organisation capture information when patients self-administer time critical medications?

Prompt 13 Learning prompt How does your organisation receive and consider information from families and carers to help avoid missed or delayed doses of time critical medications?

Prompt 14 Learning prompt How does your ePMA system help to alert staff to patients who need time critical medications?

Prompt 15 Learning prompt How does your organisation train staff to use local ePMA systems and record when patients require time critical medications?

Prompt 16 Learning prompt How does your organisation support staff to work safely when ePMA systems may not be functioning to ensure time critical medications are not missed?

Prompt 17 Learning prompt How does your organisation audit delays or omissions in time critical medications and use this to improve delivery of time critical medication?

Prompt 18 Learning prompt Is your organisation aware of any adaptations that staff are required to make to ensure they can use the ePMA system effectively in local environments?