A new HSSIB report explains why decision-making around medication needs to be revisited frequently.
The latest report from the Health Services Safety Investigations Body (HSSIB) examines the dynamic nature of clinical decision-making, and why a systems view is necessary to improve medication safety.
It looks at the systems and processes in place to support staff in identifying the need for, and making decisions about, the prescription and administration of anticoagulant medication before and after a procedure.
It also explores the role of electronic patient records (EPR) and electronic prescribing and medicines administration (ePMA) systems in supporting care in this area.
“Decision-making around medication is highly complex and dynamic, so needs to be frequently revisited to ensure that the decision remains the most appropriate,” said Clare Crowley, senior safety investigator at HSSIB.
A systems view is needed
The 87-year-old man involved in the patient safety event usually took an anticoagulant medication to reduce his risk of stroke. He was admitted to hospital where he stayed for 14 days, during which time he underwent a chest procedure. His anticoagulation medication was paused on the day he was admitted and not restarted after the procedure.
Key medical information that the clinical team needed to be aware of was not readily accessible from either the GP or hospital records.
There were a range of complex, dynamic and interacting clinical and organisational factors at play. These included bed capacity and decision-making about transferring the patient to a respiratory ward and the time the patient was off anticoagulant medication before his procedure.
The report outlines local-level learning prompts for acute NHS hospital trusts, to help to improve the safety of patients who are taking anticoagulation medication who need to have a procedure.
‘The patient safety event described in the report reflects the everyday challenges in care provision. It demonstrates why a systems view needs to be taken and that solely looking at medication aspects is inadequate,” said Crowley.
