By Julia Scott, pharmacist and CxIO (chief multiprofessional informatics officer) at Dartford & Gravesham NHS Trust
One of the simplest but most powerful benefits of electronic prescribing and medicines administration systems (ePMA) in secondary care is that drug charts no longer go missing.
Before ePMA, it was a familiar situation to lose a paper drug chart. ePMA systemically removes this risk of losing a paper chart – until the system goes down. Suddenly, all the charts are missing.
The system going down is far rarer than losing an individual paper chart, but the scale of disruption is much larger. This makes business continuity plans (BCP) essential to patient safety and a regulatory requirement.
BCP for ePMA often begins with creating a process – defining a clear trigger activation, a timeframe and a process.
At Dartford and Gravesham NHS Trust, our initial BCP approach attempted to create a process like this, but it quickly became clear that the clinical and operational context made this plan insufficient.
Traditional BCP thinking often assumes that resilience comes from detailed processes. In practice, ePMA incidents rarely unfold according to predefined scenarios.
Resilience depends less on following a script and more on informed clinical and operational judgement, supported by predefined principles, shared understanding and appropriate tools.
This leads us to three key pillars for an effective ePMA BCP.
Pillar 1: Foundations
A common assumption is that ePMA business continuity is primarily a technology challenge. While technical resilience is essential, technology alone cannot maintain safe medicines management during disruption.
Organisations need the infrastructure, people, training and assurance processes required to use fallback arrangements safely.
The most important ePMA BCP requirement is the ability to generate an up-to-date and usable copy of drug charts. Without this, there is no plan.
At Dartford and Gravesham NHS Trust, we used the native Better Meds BCP application, which generates a copy of the medicines administration record (MAR) chart for a patient every time a new prescribing or administration action is carried out.
These files are saved locally, meaning there’s a replica of each MAR, with the most up-to-date prescription information.
Julia Scott
Several key considerations underpin this foundation:
Infrastructure – Understanding site infrastructure is critical for planning for worst-case scenarios, such as power failures. Resilience depends on knowing where and how systems can fail and requires support from Estates and IT teams.
People – A large scale ePMA BCP scenario may require significant staffing to print and prepare back-up charts. Collating and stapling charts is a safety-critical process.
If an incorrect page gets stapled into the wrong bundle, there is a risk of medication error. Processes need to be in place for who will do the printing and stapling, who will check it, who has access to computers and where the paper charts will be stored.
Training – As more clinicians and staff enter practice without experience using paper drug charts, the risks increase. Staff may be unfamiliar with the pitfalls of handwritten prescriptions, including legibility and missing signatures.
It’s recommended to have some guides covering backup charts, when to write the most recently administered dose, how to create, cancel or amend a prescription and how to record witnessing when needed.
Ongoing Monitoring and Testing – Once the BCP is in place, without ongoing monitoring and testing, the well-planned arrangements may deteriorate. Ongoing assurance processes need to be in place.
Pillar 2 – Situational Judgment
It’s impossible to plan for every ePMA BCP scenario. Hospitals are complex systems, so disruption is unpredictable.
BCPs often focus on large-scale system outages, but for clinical digital teams, smaller-scale failures are equally important. In practice, an ePMA BCP must encompass a spectrum of scenarios, from an individual patient or device-level failures, ward-level disruption to organisation-wide system outages.
Starting point – what is going on?
In some cases, it is not immediately clear what type of disruption has occurred. Early in an incident, multiple reports may emerge from different areas, but the overall scope and cause are unclear.
This early phase, before the disruption is understood, is often the point of greatest clinical and operational risk.
Where there is a possibility of widespread disruption, there may be a need to act quickly to stabilise the situation and prevent unsafe variation in clinical practice, even before a full understanding of the problem has been established.
Considerations for activating a BCP
There is often an assumption that activating a business continuity plan is inherently safer than continuing to use a degraded digital system.
In reality, moving hundreds of patients from electronic to paper prescribing introduces significant clinical and operational risks of its own.
The move to paper prescribing creates a significant patient safety risk. It can also disrupt the workday, affecting patient flow.
There is an additional workload and safety-critical process to consider, including reconciling paper medication records back to the electronic system when it is up and running.
The decision to activate a full ePMA BCP for potentially hundreds of patients and thousands of prescribing and administration events must be made by the right people, with the right information.
It’s essential that you consider when elements of BCP can be informally actioned at a small, local scale, who makes the decision to activate the whole organisation’s BCP, whether activating BCP constitutes a formal incident within the EPRR structure and if your communications processes are in place.
Pillar 3 – learning and continuous improvement
EPRR teams will usually have a standard process for undertaking post-incident reviews. Smaller-scale incidents can be valuable learning opportunities to find out what worked and what didn’t.
This is essential in improving planned processes and supporting staff who may have to deal with the next incident.
A process or methodology, such as an after-action review, can be useful in capturing all relevant information, both positive and negative.
Understanding the bigger picture
Business Continuity Processes for ePMA require judgement, the ability to synthesise clinical, operational and technical information, and an understanding of human behaviour.
They need to adhere to high-level BCP principles and plan for the worst-case scenarios, such as a complete network outage, but they can also be brought to the point of failure by something as simple as not having staplers where they are needed.
The effectiveness of a plan depends on preparation, clarity in decision-making, and people’s ability to execute under pressure.
The most resilient organisations are not necessarily those with the most detailed procedures, but the ones that combine robust technical foundations with clear decision-making structures, regular testing and a shared understanding of how to operate safely when normal systems fail.
