REPORT FORM
TITLE OF REPORT:
Incorrect medication
NAME:
Practice Pharmacist
ADDRESS/LOCATION:
GP Practice
EMAIL:
DATE EVENT IDENTIFIED:
DATE REPORT
COMPLETED:
WHO CONTRIBUTED TO THE ANALYSIS?:
Practice team and Community Pharmacist
 Evidence suggests that the application of ‘Human Factors’ knowledge enhances
performance and wellbeing in the workplace and improves understanding of the complex
system interactions which contribute to significant events.
 A simple way to view the discipline of ‘Human Factors’ is to think about the interactions
between three work-related factors: People, Activity and the Environment – and how
they can combine to impact on people’s health, safety-related behaviour and patient care.
 This report can be completed after analysing the significant event on your own, or it can
reflect the comprehensive analysis carried out by your wider care team.
 The key to a more in-depth analysis is identifying the system issues and interactions that
contributed to a significant event.
 A deeper understanding of why the event happened will prompt a more focused,
meaningful and detailed Action Plan for improvement.
For more information visit the enhancedSEA website: www.nes.scot.nhs.uk/shine/
1. About the Significant Event
Please describe what happened
(Please outline in sufficient chronological detail including how it happened, who it happened to and the
location of the event).
A patient was re-admitted to the acute medical assessment unit with chest pain two weeks after being
discahrged from hospital following a NSTEMI (myocardial infarction). Upon admission, I (Practice Pharmacist)
reconciled the patient's medicines. The patient had a compliance aid. I checked the most recent discharge
letter from a couple of weeks earlier. The discharge letter had the medicines for the treatment of acute
coronary syndromes (ACS) on it, which included ticagrelor 90mg twice daily. Isosorbide mononitrate modified
release 60mg was also prescribed on this discharge letter. I checked the GP summary on the electronic care
summary for this patient and these two medicines were on it, however a prescription had not been issued for
either medicine. I checked the compliance aid dispensed by the community pharmacy and ticagrelor and
isosorbide mononitrate were not in it. I contacted the community pharmacist. She had been aware of the
patient's previous admission, however nobody had contacted her on the patient's discharge to make her
aware of any changes to the patient's medicines and therefore she had continued to dispense the original
compliance aid, omitting the ticagrelor and isosorbide mononitrate. Therefore the patient had not been
receiving the appropriate treatment after her NSTEMI. This may have been a factor contributing to her readmission with chest pain. I made the medical staff aware. I contacted the hospital pharmacist who had dealt
with the previous discharge. She said that the hospital dispenasary were responsible for faxing/emailing a
copy of the discharge to the community pharmacy upon discharge. I contacted the hospital dispensary,
however they do not keep records of discharge letters they have sent to community pharmacies. It was
therefore not possible to ascertain what had contributed to the failure in communication. This had affected
patient care and I needed to follow up on this adverse event to reduce the risk of it happening again.
What was the impact or potential impact of the event?
(Please consider what may have been the emotional effect of the event on yourself and others, where
appropriate, and the clinical, professional and organisational implications).
Due to the breakdown in the seamless care between secondary and primary care, the impact on the patient
was that she was not being treated aqequately following her NSTEMI in accordance with evidence based
guidance and she suffered further chest pain and re-admission to hospital. Her family (not patients in the
practice) suffered further anxiety.
The impact upon myself was the additional time spent trying to investigate, correct and deal with this error.
My pharmacy colleagues in the community may feel responsible that they dispensed incorrect medication in
the compliance aid through lack of information from secondary care or from the patient's GP, but knowing the
patient had been admitted, have felt that they could perhaps have been more proactive in checking whether
medication had been changed.
The GP had not prescribed the discharge medication and may feel guilty and responsible that they had relied
on the system and not ensured the patient received their discharge medication.
The event highlighted the potential risks to other patients of a similar failure.
2. Applying a Human Factors Approach
Please outline the different system factors that contributed to WHY the event occurred, taking into
account how these different factors interacted with each other and led to the event happening.
(People Factors (e.g. severity or uncertainly associated with patient condition; social and personality factors; clinician and staff training,
skills, knowledge & competence; and physical and psychological characteristics such as fatigue, stress, motivation and needs).
Activity Factors (e.g. job task demands such as mental and physical workload, decision-making, time pressure, attention levels,
distractions and interruptions, volume and complexity of tasks; and interacting medical device, tools and technology issues such as their
availability and usability).
Environment Factors (e.g. organisational issues such as how work is done, teamwork, verbal & written communication; staff levels, skill
mix & shift patterns; information flow; leadership, management and supervisory issues; physical environment factors such as lighting,
noise levels, workspace layout and design; prevailing safety culture & priorities; polices & standards; financial resources; and external
pressures).
Think in-depth about the interactions between people, the activity you were undertaking and the immediate
and wider healthcare systems and environment that you work in)
People factors:
The patient was frail and elderly and required support with medication in the form of a compliance aid. She
was unable to take any responsibility for her own medication. Her family were supportive but did not know
about the medication changes.
Activity, people and environmental interaction:
Creating discharge prescriptions whilst not a complicated task, takes time. Workload pressures, volume of
docman communication and resulting fatigue meant the GP relied on the usual back up system to save time.
My role (Practice based pharmacist) in medicines reconciliation would normally have contributed but I am not
in the practice full time and was not available on the day the discharge letter came in to the practice.
There was a lack of communication between secondary and primary care and also between the GP practice
and the community pharmacy. The discharge information from hospital dispensary was not passed on to the
community pharmacist as per the normal procedure to fax/email the discharge information for patients with
compliance aids.
The community pharmacist had been aware of the patient's admission to hospital. There are a large numbers
of compliance aids to dispense and on this occasion, the community pharmacy did not contact the GP to
check for amendments to the patient's medication during the patient's admission to hospital.
Additional activity factors:
Records of such communications are not kept and there is no follow up or checking process in place. This is
the only ward in the hospital where the hospital dispensary currently carries out this communication on behalf
of the ward technicain/pharmacist. It is therefore possible that the technicians/ pharmacists who dealt with this
discharge from a dispensary point of view were not aware of this responsibility.
Additional environmental factors: Possible inadequate IT system. The hospital dispensary is a busy
environment and this event was at a peak time.
3. Lessons Learned
What lessons have been learned from the analysis of this event (as appropriate):
 At the individual level?
 At a care team level?
 At an organisational level?
 At the interface of primary and secondary health care?
 At the interface between health and social care?
I am more aware of the pressures in the system and have learned of the lack of recording and back up of
communication from the hospital dispensary to community pharmacy. This has reinforced the importance of
robust communication systems across the interface.
The team have learned of the risks of assumptions and reliance in the processes and the event has reinforced
the responsibilities each of the team members holds.
The GPs are now clearer about the days I am available in the practice
The hospital dispensary are now aware of the lack of communication, record keeping and the need for follow
up. The hospital dispensary are also aware that they need to ensure all staff working in the dispensary are
made aware of the responsibility which they have to fax/email discharge letters for patients on this particular
ward with compliance aids to community pharmacies. The ward pharmacist who had clinically checked the
discharge letter is aware of this error and the need to communicate better with the hospital dispensary.
Everyone has learned that time needs to be taken in a busy dispensary environment to ensure such essential
communications take place to uphold patient care and patient safety.
4. Action Plan for Improvement
What action has been taken to-date to minimise the chances of this event happening again?
The event has been reported to secondary care. The prinical pharmacist has raised the issue with all staff in
the pharmacy department to alert them to this incident, to remind all staff of the importance of ensuring and
confirming there is communication of information to community pharmacies within 24 hours. They are currently
exploring ways of flagging this more effectively
I also contacted the hospital dispensary to make them aware of the failure of the system they have in place for
this communication and they are reviewing this system regularly as part of a pilot for this particular care of the
elderly ward.
I am reviewing the process in the practice to support the GPs. We are exploring ways of flagging the medical
records for patients with compliance aids and a member of the admin team has been identified to manage
discharge letters.
What further action do you plan?
(Outline your Action Plan for Improvement and how and when you will implement it together with the role and
contribution of the wider care team where appropriate. Also consider how you might share any interface issues
or external factors that have contributed to this event but which you deem to be out with your control. Think
again about taking a systems approach to improvement and consider the complex interactions between
People, Activity and Environment already identified.
If you judge that no action is necessary, please justify why this is the case)
Actions as outlined above. Once we have tagged all records I can monitor discharge communication for any of
these patients admitted to hospital.
A docman will be sent to all GPs to ensure they know which member of the admin team all discharge letters
should be returned to. This member of the admin team will also ensure discharges for tagged patients are
communicated to the relevant community pharmacy
Who is responsible for ensuring that these actions are implemented and how will these be monitored
and sustained in practice?
(Outline your role and contributions and those of the wider care team where appropriate).
The lead hospital pharmacist has responsibility for ensuring relevant changes to the communication
systems to Community Pharmacy are implemented
It will be my responsibility to tag the medical record and to liaise with the Practice Manager in identifying the
appropriate member of the practice admin team will work with me in managing the discharges.
If you did not have the opportunity to analyse this event with colleagues, what were the barriers?
(Please complete where applicable).
n/a