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The Royal Pharmaceutical Society (RPS) has told a coroner who examined the death of a woman given paracetamol and another medicine containing the painkiller while in hospital that alerts should be built into electronic prescribing systems to warn prescribers about the “unacceptable duplication of medicines”. 

An inquest concluded 55-year-old Paula Doreen Hughes died as a result of “an unintended therapeutic excess of paracetamol”. She was admitted to Queen Elizabeth Hospital, Woolwich, on January 6, 2022 after suffering a fractured humerus after a fall the previous evening.

The coroner for London Inner South said that on January 7, Ms Hughes “received paracetamol in excess of the recommended dose largely as a consequence of paracetamol being inadvertently prescribed in addition to co-codamol, a paracetamol-containing drug”.

Pharmacy review failed to detect concurrent prescription

The coroner said a pharmacy review failed to detect the concurrent prescription and both drugs were administered together on three or four occasions until the duplicate prescription was deleted on January 8.

The coroner said the overdose of paracetamol was not detected until the morning of January 9 even though Ms Hughes’ condition started to deteriorate from around midday the day before. She was admitted to intensive care with acute liver failure.

The coroner said the failure to detect the overdose in time meant she did not “receive timely treatment with n-acetyl cysteine which would have mitigated the toxic effects of paracetamol on her liver”.

The inquest ruled Ms Hughes died from acute (fulminant) hepatic failure, paracetamol overdose, ischaemic heart disease, urinary tract infection, diabetes mellitus and excess alcohol consumption.

Risk of concurrent paracetamol-containing prescriptions is national concern

Insisting “the risk of concurrent prescriptions of paracetamol-containing drugs is of wider national concern”, the coroner said all healthcare professionals involved in Ms Hughes’ care were aware co-codamol contains paracetamol and should not be prescribed with paracetamol.

The coroner, however, said two prescribing doctors failed to recognise she had been prescribed a paracetamol-containing drug, two nurses were not aware they were administering two paracetamol-containing drugs and a pharmacist failed to identify the concurrent prescriptions “during reconciliation”.

The coroner also said Lewisham and Greenwich NHS Trust did not adopt the Cerner prescribing system when it was introduced. The coroner noted the system “offers a duplicate checking functionality that is not a standard feature”.

The coroner described the Trust’s response to the incident, in which it introduced “a hard stop” to the electronic prescribing system “which eliminated concurrent prescriptions of paracetamol-containing drugs” and put in place “further refinements of the system” as “swift and commendable”.

National oversight to coordinate work with secondary care system suppliers

In its response to the coroner’s report, the RPS said “there may be situations where the duplication of certain medicines, such as insulin, may be acceptable”.

“For example, the acceptable duplication of insulin dosing where a patient may need a long-acting insulin prescribed as part of their regime in conjunction with a short acting insulin, or where regular morphine and PRN/as required morphine is co-prescribed for breakthrough pain,” it said.

However, the RPS added: “Steps could be taken to try and build alerts and warnings for the unacceptable duplication of medicines into these electronic prescribing systems to make them safer.

“This would require national oversight to coordinate work with secondary care system suppliers.”

The RPS said “people issues” as well as “technology issues” needed to be addressed to prevent concurrent prescriptions of paracetamol-containing drugs and prescribing errors which could result in “therapeutic excess of paracetamol”.

“There were opportunities for healthcare professionals without the need for any digital intervention to identify the medication error,” the RPS said.

“Electronic prescribing and medicines administration systems and clinical decision support tools have been widely adopted in healthcare settings to support clinicians in making prescribing decisions and reduce the number of prescribing errors.

“They, however, do not replace the personal responsibility and accountability for prescribing and clinical decision-making for healthcare professionals.”

The RPS said it was important to remind clinicians about the risks of prescribing paracetamol-containing products and duplication.

“Professional leadership bodies can highlight this particular safety concern and raise awareness of national resources such as the British National Formulary which have a particular reference to safe paracetamol prescribing,” it said.