HSSIB have published a report examining the case of a patient who did not receive time critical Parkinson’s medication while attending an emergency department. The report charts the first in a series of investigations exploring patient safety events in NHS organisations to understand why patients may not receive medications as planned.
This particular investigation explored the systems and processes in place to support staff to recognise, prescribe and administer time critical medications in the emergency department (ED). It also explored the role played by electronic prescribing and medicines administration (ePMA) systems in supporting care in this area.
In the case they examined, an 85 year old patient attended the ED following an outpatient appointment and stayed in the ED for three days. The patient usually took his medication at home four times a day. During this time in the ED, he should have received a total of 18 doses of his Parkinson’s medication. However, seven doses were not given and three doses were given late.
This meant that only 8 of 18 doses of Parkinson’s medication were provided to the patient on time. The patient was transferred to a medical ward where his Parkinson’s symptoms deteriorated and he lost the ability to swallow. The patient died 4 weeks after his admission to the ward. The coroner reported Parkinson’s as a factor leading to the patient’s death.
Key findings in the investigation included:
- The patient spent 52 hours in the ED, and 44 of those he was cared for in a corridor because of demand on ED services.
- This created additional challenges for ED staff and speciality teams who had limited opportunities to store medication brought from home.
- The electronic patient medication administration system did not include a function to alert staff about patients who required time critical medications
- The ED had no dedicated pharmacy support to help staff in providing care to these patients.
- Staff were not able to check information with the patient’s GP practice or Parkinson’s specialty team at the time the patient’s medication was prescribed in the ED, as this was outside of these services’ working hours.
- Staff received contradictory information from the patient’s son and the GP summary care record about the dosage of medication the patient required. The GP summary care record was taken as the most accurate record, but the information it contained was incorrect.
The report makes a safety observation for NHS Trusts to use the information in the Royal College of Emergency Medicine’s Quality Improvement programme on time critical medications. A key finding in the investigation was that the Trust involved in the patient safety event did not participate in this programme. There are also 16 learning prompts for providers which may help staff identify and think about how to respond to specific patient safety concerns. An example of a prompt is ‘ how does your organisation ensure that patients need time critical medications are identified as soon as possible on arrival to the ED?’
Deinniol Owens, Deputy Director of Investigations at HSSIB says: “ When patients are in the ED, it is crucial that, alongside any emergency treatment needed, medication they require for other conditions is prioritised. The case we examined during this investigation was a sobering example – if patients do not receive medication for their Parkinson’s it can make them seriously unwell, and doses not being given on time increases the risk of harm and reduces the effectiveness of the medication. It is distressing for patients and their families, and in this case the family felt they were not always listened to even though they communicated his needs and emphasised how important the correct timing of the dosage was.
“Our investigation makes a number of important findings in relation to how time critical medications are considered in emergency departments. We are sharing this at a national level to prompt providers to look at on how they administer critical medication, in a busy and challenging emergency environment and how they ensure patients receive medication in a timely and safe way”
Dr. Adrian Boyle, President of the Royal College of Emergency Medicine commented on the report saying: “First and foremost, we extend our deepest condolences to the patient’s family. Their courage in sharing their loved one’s experience via this report is commendable, and we sincerely thank them for that.
“What is detailed should serve as a call to action for all Emergency Department (ED) clinicians. No patient who enters an ED, should fear their health will be put at risk because they are unable to access their regular prescription when they need it.
“Asking patients if they take any time critical medication, and when their next dose is due, should be one of the questions every clinician asks. This simple enquiry becomes increasingly pertinent given the backdrop of the extreme long A&E stays more and more people are having to endure. In this tragic case - a shocking 52 hours.
“The HSSIB report should be essential reading for all EM clinicians, and RCEM will continue to work to raise awareness of TCM to help ensure tragic incidents such as those it details cannot, and do not, happen again.”
This is the first in a series of investigations by the HSSIB exploring medication related harm – full details are available at: https://www.hssib.org.uk/patient-safety-investigations/medication-related-harm/
