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EPMA Systems & Safe Discharge – HSIB Report

The Healthcare Safety Investigation Branch (HSIB) have published a report on electronic prescribing and medicines administration systems (EPMA) and safe discharge.

The HSIB investigation was triggered by a reference event involving anticoagulants that met defined Outcome Impact, Systemic Risk and Learning Potential criteria.

The event highlighted issues with discharge communication.

The HSIB made four recommendations to NHSX relating to electronic discharge processes (including the interface between EPMA systems and electronic discharge systems), use of standardised testing processes for EPMA configuration, a process for recognising and acting on digital issues in the Patient Safety Incident Management System (PSIMS) and the development of interoperability standards for medication messaging.

The HSIB also made nine Safety Observations – including that healthcare professionals may benefit from training in handover communication, that standarded alerts on clinical systems should be pursued and that medicines reconciliation processes in the community would benefit from review.

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