Patients are being put at risk by partial use of electronic medication systems, according to an official investigation.

Electronic prescribing is being “poorly implemented”, leading to crucial information not being shared with practices and pharmacies, according to the Healthcare Safety Investigation Branch. It undertook the investigation after the death of a cancer patient who received a double dose of anticoagulant after misuse of an electronic medicines system. The patient died from the cancer.

Investigators found that hospital staff often switch between paper and digital records. The patient was taking an anticoagulant on admission to hospital – but it was stopped. The message did not reach her local pharmacy which continued to dispense the medicines, which she then resumed taking. Investigators set out a series of recommendations calling for improved information sharing, improved messages about medication and alert systems to guarantee safe patient discharge.

HSIB director of investigations Dr Stephen Drage said: “ePMA systems are a positive step for the NHS – research shows if implemented well they can reduce medication errors by 50%. Our report is highlighting the risks if e-prescribing is not fully integrated and doesn’t create the whole picture of the patient’s medication needs from when they arrive to when they return home. The more efficient the system, the better the communication is with the patients, families and between NHS services.”