OBJECTIVES: Medication errors at transitions of care, such as at hospital admission or discharge, can result in avoidable harm and associated health care costs. This study aimed to estimate the number and burden of medication errors associated with prescription information transfer within the National Health Service (NHS) in England and the impact of implementing an interoperable prescription information system (a single digital prescribing record shared across NHS settings) in reducing these errors.

METHODS: We constructed a mathematical model, based on published data, to estimate the annual prevalence of medication errors caused by incorrect transfer of prescription information at key hospital transitions (admissions, discharges, inter- and intra-hospital transition) in the NHS in England. We also estimated the burden associated with these errors (healthcare resource use and deaths). Finally, we estimated the impact on error prevalence (and burden) of implementing an interoperable prescription information system.

RESULTS: Around 1.8 million medication errors were estimated to occur at hospital transitions in England, annually, affecting approximately 370,000 patient episodes. Harm from these errors would affect around 31,000 patients, leading to 36,000 additional bed days of inpatient care (costing around £17.4m) and 45 deaths. Implementing an interoperable prescription information system is estimated to reduce error prevalence by approximately 40%. As a result there would be around 12,500 fewer people who experience harm, 14,000 fewer bed days used (saving around £6.6m), and 20 lives saved annually.

CONCLUSIONS: An interoperable prescription information system could provide major benefits for patient safety. Likely additional benefits include healthcare professional time saved, improved patient experience and care quality, quicker discharge, and enhanced cross-organisational medicines optimisation. A limitation of this analysis is uncertainty due to lack of primary source data from English settings. However, our findings still strengthen the case for adopting interoperable prescription information systems, from a safety and economic perspective.