Source · HSSIB Patient Safety Investigation
Medication not given: administration of time critical medication in the emergency department
HSSIB’s introductionMedication 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 receive the medication they need whilst in hospital, at home or in a nursing home.
Published 5 December 2024
Published
Medication
Communication and decision making
Continuity of care
Indexed content
1 observation
18 learning prompts
Safety Observations
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
How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED?
Who in your patient pathway is responsible for identifying patients who need time critical medications?
Who in your patient pathway is responsible for prescribing time critical medications?
How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed?
What aids or tools are available in your organisation to help staff to identify patients who need time critical medications?
What pharmacy support is available to staff in ED to support in the care of patients who need time critical medications?
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.
When the medication was prescribed, the morning dose was incorrect.
A dose was prescribed but not given on day 3.
How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?
How does your organisation support patients to self-administer time critical medications, when appropriate?
How does your organisation capture information when patients self-administer time critical medications?
How does your organisation receive and consider information from families and carers to help avoid missed or delayed doses of time critical medications?
How does your ePMA system help to alert staff to patients who need time critical medications?
How does your organisation train staff to use local ePMA systems and record when patients require time critical medications?
How does your organisation support staff to work safely when ePMA systems may not be functioning to ensure time critical medications are not missed?
How does your organisation audit delays or omissions in time critical medications and use this to improve delivery of time critical medication?
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?