Medication errors remain a significant challenge across UK hospitals, with an estimated 237 million errors occurring each year in England. Prescribing errors are reported at 8.9%, while medication administration errors reach 18.6%, with even higher rates for intravenous medicines.

Why Medicines Management Optimisation Is Critical for Improving Patient Safety

In a recent report, it has been shown that, globally, medication-related errors are recognised as a leading cause of harm, with a financial impact estimated at $42 billion.

With increasing national focus on reducing harm, including the World Health Organisation’s ambition to halve medication-related harm and the NHS’s commitment to becoming one of the safest healthcare systems, Mersey and West Lancashire Teaching Hospitals NHS Trust (MWL) recognised the need to strengthen medicines optimisation and improve visibility across inpatient care.

Facing Challenges with Legacy EPMA Systems

Like many organisations across the country, MWL faced limitations with its existing Electronic Prescribing and Medicines Administration (EPMA) and supporting systems. A key issue was the lack of transparency across EPMA, ICNet, and ICE, making it difficult to identify clinical issues and determine what required prescribing or amending.

As a result, identifying prescribing changes, tracking outstanding tasks and prioritising high‑risk patients became more challenging. This lack of visibility contributed to missed doses, increased incident reporting and inefficiencies in day-to-day workflows. Ward processes were often time-consuming and inconsistent, with multiple logins required and variation in ward round standards. Overall, the approach was reactive rather than proactive.

Creating a More Connected, Proactive Approach

To address these challenges, the pharmacy team developed an Interactive Medicines Management Pharmacy Hub and Ward Dashboard solution in 2020.

Bringing Medicines Data Together

Bringing together data from EPMA, ICNet and ICE, the Hub provides a single, clear view of medicines-related risks, clinical priorities and outstanding tasks. The dashboards refresh regularly and are accessible from one landing page, reducing the need to move between systems and improving efficiency.

This approach reflects the capabilities of modern EPMA systems such as CareFlow EPMA, which is designed to consolidate prescribing, administration and clinical information into a single, integrated view.

Embedding Safer Pharmacy Workflows

By embedding pharmacy clinical standards into everyday workflows, the system helps teams quickly identify prescribing errors, missed doses, and high-risk medicines. It also supports safer prescribing and more consistent care across wards.

88% of Staff Reported Improved Efficiency

Staff engagement with the system has been strong. A department survey shows that 95% of staff use ward dashboards, with 76% accessing them daily, while 82% use the Pharmacy Hub routinely.

Feedback highlights clear benefits. 88% of staff reported improved efficiency, 75% reported improved patient safety, and 85% stated that the system makes their job easier.

Some barriers remain, including limited digital infrastructure, such as insufficient access to devices, and the need for ongoing training to support new or returning staff.

An image of a pharmacist and a System C character at a Pharmacy counter looking at a pharmacy system.

Improving Pharmacy Efficiency Through Data-Driven Medicines Management

Following implementation, the Trust has demonstrated sustained improvements in activity, efficiency, and patient safety over four years.

Pharmacist-checked items increased by 17%, while prescribed and amended items increased by 131%, rising from 54,137 to 124,998. Inpatient pharmacy-ordered items increased by 78%, from 39,684 to 70,729, and completed discharge prescriptions increased by around 14%.

Medicines reconciliations also increased, and the internally developed Weighted Activity Score rose by 44%. This reflects greater productivity and a stronger focus on high-value clinical tasks.

Enhancing Patient Safety and Clinical Productivity

In terms of patient safety, overall missed doses decreased despite increased prescribing activity. Missed doses due to drug unavailability were also reduced, while critical medicine missed doses remained extremely low. Only minimal increases were linked to supply issues.

MWL’s approach shows how bringing together data and workflows can support safer, more efficient care. By improving visibility and prioritisation, the Trust has empowered clinical teams to focus on what matters most.

Next Steps

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For more information about some of the stats used, see this article.

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