The HSSIB report, the third and final in a series of investigations exploring patient safety events in NHS organisations to understand why patients may not have received medications as planned, explores the systems and processes in place to support when patients are discharged into the community with medications.
The investigation also explores the role played by electronic prescribing and medicines administration (ePMA) systems and electronic patient record systems (EPR) in supporting care in this area.
While the investigation focused on a single case involving a diabetic patient, the HSSIB says the findings offer valuable insights that can inform wider discussions and drive safety improvements across the NHS.
Some of the more detailed key findings in the case included:
- On the patient's admission, conflicting information in his patient records created challenges for staff in understanding whether he was taking any medication to manage his diabetes.
- The patient's individual circumstances were considered by the hospital diabetes specialist nursing team when arranging education for self-administering his insulin. However, there was no documentation available to establish whether the patient was able to effectively self-administer his insulin.
- The patient's need for district nursing support for insulin administration was documented and interpreted differently by different hospital teams, and between hospital and district nursing teams.
- The processes for managing medications on the ward and in the hospital's discharge lounge did not identify that the patient was discharged home with two insulin pens, including one he did not need. This resulted in confusion for the patient about which one he should use.
- A mismatch between demand and capacity within the district nursing service often led to visits being overscheduled and time restrictions during patient visits.
- Multiple healthcare providers were involved with the patient's care. They used different EPR systems that did not interact to share information about the patient's care and referral status.
Rebecca Doyle, safety investigator at HSSIB, said: 'While individual cases can be complex, this incident clearly highlighted persistent challenges with information sharing — an issue we continue to see in investigations that explore communication and the interaction of digital systems. This information sharing is critical to keep people safe at home, managing their medical conditions and avoiding readmission to hospital.
'It also underlined the importance of education and tailored support in hospital, to ensure patients don't miss or delay critical medication, particularly when they need to self-administer. In this case, the patient's emergency readmission after not taking his insulin shows the real potential for harm when these systems don't work as intended.
'The insights and analysis presented in the report, along with the learning prompts, offer valuable guidance — not just for trusts and providers, but also for those working at a national level on discharge planning and improving the interoperability of electronic patient record systems. Ultimately, improving information flow and patient support at discharge is not just an administrative task — it's a matter of patient safety.'
