Investigation into the role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

Report details death of 79 year old patient, admitted to a Trust on Black Alert, for pain in hip after a fall, whose name sticker was put on another patient’s warfarin chart in error,which was spotted by a ward pharmacist, but patient subsequently developed internal bleeding.

SPS commentary:

An inquest concluded that the bleeding he developed after being prescribed warfarin was a contributing factor in his death.

Report notes ward-based clinical pharmacy services can play an important role in helping the multidisciplinary team to identify and reduce high-risk medication errors, but there is significant variation in how ward-based clinical pharmacy services are staffed, organised and developed and in the organisation and understanding of the role of ward-based clinical pharmacy services in the NHS between the point of initial medicines reconciliation and discharge. Furthermore, the impact of a complex patient caseload or operational pressures on the ability of ward-based clinical pharmacy services to operate and adapt effectively is not well studied.

Report recommends that:

  • Royal Pharmaceutical Society, supported by NHS England and NHS Improvement, should provide guidance on models of hospital clinical pharmacy provision. The guidance should provide information on the models’ ability to enhance safety and healthcare resilience and include consideration of the appropriate skill mix and experience within the clinical pharmacy team.
  • NHS Specialist Pharmacy Service should update its resource on the prioritisation of hospital clinical pharmacy services to facilitate the dissemination of developments in good practice and policy with respect to pharmacy prioritisation and the issues highlighted in this report.

Healthcare Safety Investigation Branch