NHS Connecting for Health ceased to exist on 31st March 2013. This website is therefore not being updated. For up to date information about systems and services visit the Health and Social Care Information Centre website at www.hscic.gov.uk/systems

You are here: Home Services & Applications ePrescribing Clinical safety

Clinical safety

ePrescribing can support the entire medicines use process, enabling medications to be managed electronically from prescribing through to supply and administration. The resources here, although no longer maintained, may be useful to trusts planning ePrescribing implementations.

This section contains information about how to assess the clinical safety of ePrescribing systems, and to avoid known risks.

Design for patient safety - guidelines for safe on-screen display of medication information - February 2010

Unclear, incomplete and/or confusing displays of information on ePrescribing systems can increase the possibility of people making mistakes, potentially resulting in harm to patients. ePrescribing systems must therefore be designed to minimise the likelihood of errors occurring.

This booklet – a collaborative effort between NHS Connecting for Health and the National Patient Safety Agency - provides guidance to healthcare information technology (HIT) vendors, those procuring HIT software and patient safety and risk management professionals on this crucial area. It includes recommendations for the safe on-screen display of medicines information, addressing known errors identified from both handwritten and electronic prescriptions, and suggests ways in which these can be avoided in the future.

Reducing the risk of mis-selecting opioid preparations in electronic systems - September 2009

Mis-selection of medicines is one of the new risks associated with the move from paper-based to electronic systems for medicines management. And opioids carry particular risks as the doses at which they may be used can vary by 10 fold. This means that the preparations available may also vary by up to 10 fold in their concentration or strength, thus increasing the risks of a mistake being made if , say, a zero is not seen or the concentration is mis-read.

Reports of errors have identified the format in which the medicines were displayed for selection during the prescribing process as a probable contributory factor. Consequently NHS Connecting for Health, working closely with the National Patient Safety Agency, has authored a paper - Lessons learnt on mis-selection of opioid products (PDF, 138Kb) - which identifies lessons learned that might be applied to reduce the risk of mis-selection of opioid products. The paper is likely to be of interest to both individuals involved in the design and implementation of ePrescribing systems, and those who use them.

Tall Man Lettering report - July 2009

This report, entitled 'The Use of Tall Man Lettering to Minimise Selection Errors of Medicine Names in Computer Prescribing and Dispensing Systems' (PDF, 434Kb) explores whether the use of Tall Man Letter by ePrescribing system suppliers can help reduce the number of medicine selection errors.

ePrescribing hazard framework - October 2008

The ePrescribing programme has worked with the National Patient Safety Agency to develop and publish a set of guidelines (PDF, 274Kb) outlining a core set of design-related safety features that ePrescribing system suppliers should incorporate in their systems. The guidelines identify hazards that should be mitigated in order to ensure that previous lessons learned are not forgotten.