Douglas Hodges
12 Oct 2017 · Coroner Heidi Connor · Nottinghamshire
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of clinical urgency communication in community pharmacy prescription download system
“As matters stand, in a community pharmacy setting, there is no way of communicating clinical urgency between prescriber and pharmacy staff at the time the prescription is downloaded. A large number of prescriptions are downloaded every day by pharmacies. Urgent and non-urgent prescriptions look the same on the system. It is only at the labelling stage that any clinicians' comments can be seen.”
2. absence of red exclamation mark urgency indicator in NHS Spine prescriptions
“We were told that a different system (Vision) is used in scenarios where a pharmacy is run by a GP practice. This system is often used in rural settings. The Vision system allows for a prescription to be marked with a red exclamation mark at the point of downloading, where a prescription is urgent.”
3. misleading help documentation suggesting red exclamation mark functionality
“the investigation, an experienced clinical pharmacist who works at the GP practice attended the pharmacy and looked at the system in question. When 2 accessing the 'help section' of the software, the information she saw suggested that the red exclamation mark system was available and she questioned why this was not being used. It is not clear why this information is included in the 'help section' of software that does not currently support this function. It clearly led to confusion”
4. inconsistent prescription download cutoff times leading to delayed urgent medication
“1. I heard evidence from the patient safety manager of Wells Pharmacy Group, who told us they are trialling a system which includes the following provisions : a. Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day. We were told that urgency and delivery instructions would then be picked up at the labelling stage. b. Pharmacists are required to check at the end of each day whether there are prescriptions which have been sent to”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day.”
Later report
“The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued.”
Responses
2017-0290-Response-by-NHS-Digital.pdf ↗· NHS Digital
Stated action · up to 24 months
“The EPS Enhancements survey took place in August 2017 and a”
2017-0290-Response-by-Well.pdf ↗· Cegedim
Stated action
“An improved reporting mechanism has been developed to record actions and results of the audit and support the ongoing maintenance of the changes which have been implemented.”