Source · HSSIB Patient Safety Investigation
Medication not given: anticoagulation before and after a procedure
HSSIB’s introductionThis is the second of three locality-based patient safety investigation reports, which presents the findings of an investigation into a patient safety event at an acute hospital trust and identifies factors relevant to learning in other NHS organisations. It also identifies learning in relation to electronic prescribing and medicines administration (ePMA) systems. This investigation will be used, alongside learning from past HSSIB and Healthcare Safety Investigation Branch investigations, to inform an upcoming national investigation into the safe use of ePMA systems in acute hospitals.
Published 13 March 2025
Published
Medication
Communication and decision making
Continuity of care
Indexed content
10 learning prompts
Learning Prompts
How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed?
How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication?
Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused?
Does your organisation have a process for ensuring that guidelines that cross-refer to other relevant guidelines are reviewed together to ensure they provide consistent advice?
How do you ensure that all members of the multidisciplinary team with relevant expertise are included in clinical guideline reviews?
Does your organisation have processes in place to ensure that when new evidence on newer anticoagulants becomes available it is considered for inclusion in local guidance as soon as possible?
How does your organisation support staff to find and readily access anticoagulation related guidelines?
Does your organisation ensure it is easy for staff to access information in patients’ records relevant to decision making about anticoagulant medication?
Does your ePMA system identify patients with paused time-critical medication that may warrant a review?
How does your organisation consider factors relating to equipment which may affect the successful implementation of EPR/ePMA systems?