What's Happening?
NHS England has raised concerns about the disabling of decision-support alerts in hospital prescribing systems following the death of Paula Doreen Hughes from a paracetamol overdose. Hughes, aged 55, died on January 10, 2022, after being prescribed both
co-codamol and paracetamol concurrently at Queen Elizabeth Hospital, Woolwich, London. The assistant coroner for Inner South London, Liliane Field, concluded that the medication error led to an unintended therapeutic excess of paracetamol. The coroner's prevention of future deaths report (PFD) emphasized that the pharmacy review failed to detect the concurrent prescription, resulting in the administration of both drugs on multiple occasions. NHS England and the Royal Pharmaceutical Society (RPS) responded to the PFD, stressing that while electronic prescribing systems can alert clinicians to such errors, these alerts should not replace professional responsibility. The incident has prompted NHS England to include therapeutic duplication as a theme in its 2025 ePrescribing Risk and Safety Evaluation toolkit.
Why It's Important?
This incident underscores the critical role of electronic prescribing systems in preventing medication errors in healthcare settings. The failure to enable alerts for concurrent prescriptions highlights a significant gap in patient safety protocols. The case illustrates the potential consequences of 'alert fatigue,' where frequent alerts may desensitize healthcare professionals, leading to critical warnings being overlooked. The incident has prompted a review of electronic prescribing systems to ensure they effectively support clinical decision-making without replacing the accountability of healthcare professionals. The broader implication is a call for improved integration of technology in healthcare to enhance patient safety while maintaining professional oversight.
What's Next?
NHS England plans to prioritize the review of high-risk prescribing scenarios in its upcoming 2026 release of the ePrescribing Risk and Safety Evaluation toolkit. This review aims to address the issues highlighted by the incident, ensuring that electronic prescribing systems are better equipped to prevent similar errors. The Royal Pharmaceutical Society has called for national oversight to coordinate efforts with secondary care system suppliers to build more effective alerts into electronic prescribing systems. These steps are intended to prevent future medication errors and enhance the safety of prescribing practices across NHS trusts.
