Electronic prescribing: how it can improve the delivery of time critical medications

76% of Parkinson’s medications were given on time at NHS Ayrshire & Arran hospitals in 2023, up from 41% in 2013. The team shares how using electronic prescribing has played a vital role in improving patient care and safety.

Last reviewed
  • Inpatient care and medicines management
  • Service improvement
Resource type
  • Case studies
  • Q&As
  • Doctor (Geriatrician)
  • Doctor (Neurologist)
  • Doctor (Other)
  • Nurse (other)
  • Nurse (Parkinson's nurse)
  • Pharmacist
  • Complex
  • End of life
  • Maintenance

Here, Nick Bryden, Parkinson’s Nurse Specialist, Robert Gouck, Parkinson’s Nurse team and Richard Cottrell, Principal Pharmacist Digital Health and ePrescribing, share with us insights from their work to support other hospitals to improve the delivery of time critical medications.

3 members of NHS staff stood in a row smiling.

From left to right Richard Cottrell; Michelle McLuckie who was involved in her capacity of Head of Systems, Development and Implementation, Digital Services; and Nick Bryden.

This project has developed in phases, can you talk us through that journey?

We used electronic prescribing to audit. Then we introduced medication alerts and dashboards.

Phase 1: monthly auditing

Nick: Phase 1 was an audit to tell us if medications were given on time. That started when I came into post, around 2010. Originally that audit was done with mental arithmetic because I did not know that my colleague Richard existed at that point! So I would print out the Medicines Administration Profile (MAP) for one patient, that includes every administration of every Parkinson’s medication the patient was given while they were in hospital through electronic prescribing. Then with a calculator, I would work through every single drug administration to see if the drugs were given on time. That took a long time and I did that for 4 years.

Richard automated this reporting using ePrescribing. The report includes every medication in the British National Formulary (BNF) for Parkinson’s for the previous month in 4 domains: morning, lunchtime, teatime and bedtime. I had a conversation with Richard and within 24 hours he had given me an audit of every administration of every Parkinson’s medication in the BNF, that had been administered on electronic prescribing for a number of years within NHS Ayrshire and Arran.

Now, on the first of every month at 7am, our ePrescribing system automatically runs a report to audit the previous month. The report shows the Parkinson’s team and clinical nurse managers the data for every ward in NHS Ayrshire & Arran across multiple hospitals.

Electronic prescribing makes auditing more accurate.

Richard: This wouldn’t have been possible without Hospital Electronic Prescribing and Medication Administration (HEPMA) being implemented across our wards and a properly resourced HEPMA team within the pharmacy.

Phase 2: daily reports (2015 onwards)

Nick: Phase 2 began with another conversation with Richard. I asked if we could use electronic prescribing to alert us when patients came into hospital, and we could! Now, at 7am every morning, 365 days a year, we get a report for the previous 24 hours that tells us the patient’s name, their Community Health Index (CHI) number or their unique NHS number, their hospital and ward.

It also provides their prescribed medication for Parkinson’s, the time it’s prescribed, the time it’s given by the nurse, and the discrepancy between those 2 numbers. The report is colour coded to show if medications are being given within 30 minutes of the prescribed time. That’s been the biggest benefit to the Parkinson’s nurse team as that lets us know when our patients are in hospital, we can support them better and also support the nurses on the ward.

Phase 3: Parkinson’s medicines ward prompts (2018 onwards)

Nick: Next, we wanted to do more to help the patients on a daily basis on the ward. Just because we have the report, that doesn’t mean that we have the time to check it every single day. So in phase 3, we developed the Parkinson’s medication prompts, known locally as “the tulip system”. Simply, this utilises an electronic whiteboard or television on the ward with the patients’ names and bed numbers.

A tulip icon appears automatically on the board when the patient is prescribed Parkinson’s medications, so that staff on the ward don’t have to identify the patient or their unique patient number to know that a Parkinson’s drug is due. 

This is what the tulip icons look like, and what the colours mean:

A graphic icon of a grey tulip flower head.

A grey tulip icon means a patient is not due any medication.

A graphic icon of a green tulip flower head.

A green tulip icon means that a patient is due their medication within 30 minutes. The icon will flash until medication is administered.

A graphic icon of a red tulip flower head.

A red tulip icon means that a patient's medication is overdue.

Phase 4: electronic dashboard

Nick: In 2023 we introduced an electronic dashboard. This is another system but the systems that we have: our patient management system, electronic prescribing and the whiteboard, all talk to each other. This has never been done before, as far as I am aware.

This program accesses the data held in the electronic prescribing system to produce a dashboard which shows details of every Parkinson’s medication administration in NHS Ayrshire & Arran in the last 12 months.

With the dashboard, we can analyse a single ward, all the wards, or even certain disciplines like care of the elderly. We can even analyse how good we are at administering medication at certain times of the day. This helps us to drill down and work with colleagues on wards to understand the challenges and find solutions.

In the future, we can go further and develop our reporting using this information.

What impact has using electronic prescribing had on delivering time critical medications in your hospital?

Nick: In 2014 when we started auditing electronically, 41.27% of Parkinson’s medications were given on time. In 2023, we are at 76.33% across NHS Ayrshire & Arran.

In some areas that increase has been far greater. Some wards have achieved over 80% in 2023 and the ward with the most administration of Parkinson’s medications in the last twelve months have achieved 90%. Staff have worked so hard on this issue.

Richard: We have demonstrated improved timeliness of Parkinson's medicines, reducing complications and distress in this patient population. We've also been able to use derived tools to optimise stock holdings on the wards based on actual administrations to drive down missed doses and delayed administrations.

Tips for hospitals: how to use electronic prescribing to improve the delivery of time critical Parkinson’s medications

  • Be positive. Emphasise the increase in the standard of care and how much better it is for the patients.
  • Let staff get used to electronic prescribing. If electronic prescribing is new to your hospital, allow people to get used to it before you start this type of project. Teams need to understand the system before they can start to play with it. 
  • Start small. Start on 1 or 2 wards. Do not try to switch this on everywhere straight away.
  • Involve the right people. Bring together a small focus group including the Parkinson’s nurse service, ward pharmacist, ward managers and staff, patients and relatives.
  • Speak to your quality improvement leads. Ask the Parkinson’s UK Service Improvement and Grants team to help you to think about how you can address time critical medications. Contact [email protected] to start a conversation.
  • Use evidence from existing projects to gain support for using electronic prescribing in this way in your organisation. We have 10 years of data and there are other projects throughout the UK. 
  • Get buy in early. Work with ward managers and your clinical nurse managers, before starting the system to get buy in.
  • Engage stakeholders before starting any data work to understand the situation and potential for use of data. Data in a vacuum is useless.
  • Don't reinvent the wheel. Speak to established sites and reuse existing tools wherever possible.
  • Set your baseline. Do not tell people that you are auditing them to begin with because when you tell people there is often an increase in delivery of medication on time. You want a true reflection of how difficult it is to give medications on time and that gives you a baseline.
  • Target training and support where needed. We run a yearly Parkinson’s education day but training can be indirect. For example, when visiting the wards to review a patient or calling a ward on the telephone, you can talk about why that patient needs to get their medication on time. Give examples such as without it their walking will be worse or they will be more agitated or depressed. 

How transferable is this work to other hospitals?

Nick: Very transferable. All that hospitals require is electronic prescribing. Richard has already written the programmes so there is no reason why someone needs to rewrite that. The team here at NHS Ayrshire & Arran will share the monthly audit and daily report and explain how to implement these. Our electronic prescribing team will support your electronic prescribing team in implementing this. We won’t do it for you but we will support you.  

We have already collaborated with various areas across the UK.

To connect with the team at NHS Ayrshire & Arran about the reports, email [email protected]

Can you explain the pharmacy team’s role in this work?

Richard: Pharmacy continually works with nursing staff to optimise the supply and administration of medicines within our hospital sites. My role within the pharmacy HEPMA (ePrescribing) team enabled us to take a new approach to looking at administrations of medicines using the data collected within our HEPMA system.

Over the years I've been able to develop the ways in which we can use this information in Parkinson's patients. Auditing performance relating to the administration of medicines, the whiteboard prompts and dashboards are only a few of the many benefits that HEPMA (ePrescribing) has given us.


Can you explain the role which the IT team has played in this work?

Richard: At NHS Ayrshire & Arran HEPMA (ePrescribing) is managed by pharmacy. To display information on the ward whiteboards, support from digital services was required as they maintain the whiteboard system. Essentially it was a shared piece of work with my team developing the method of getting the information required from HEPMA (the query) and Michelle’s digital services team building the way of displaying this into the whiteboards.

Many hospitals that have ePrescribing will not have whiteboards on the wards. How essential is this?

Nick:The whiteboards have been a great help as a tool which alerts staff when medications are due but they aren't essential. If you don’t have whiteboards an alert can be sent to a ward computer, tablet, or even a ward mobile phone, so there are other ways of receiving an alert.

Some of our wards do not have the whiteboard system so instead they use pill timers. The ward team will print out the medication times on a sheet, put it up in the nurses’ station and set pill timers which we supply them with.

Robert: The key thing is to let staff know when it is time to administer medication.


How have your colleagues in different teams across the hospital worked collaboratively to implement this?

Nick: We started this project by creating a focus group. You have to build relationships with colleagues in other disciplines.

The Communications team were vital because they kept colleagues across all hospitals informed about the project and how to get involved. 

How important has communication been to this work?

Nick: I’ve learned a lot about how to approach this over the years! We need to remember that these are busy wards and lots of colleagues still don’t know that Parkinson’s medications are time critical. You have to take people with you.

Now I phone the ward and say that I can see there is a difficulty with medications and ask how we can help them to deliver that a little bit better. The daily report is not used by us to police or castigate the wards. It is an aide to identify wards or specific times of the day within a ward that need attention.

We run Parkinson’s education days and offer training on the wards because you have to go to the people. Don’t expect them to be able to come off the ward. Education on the wards should be short, 5 or 10 minute sessions, at lunchtime.

As Parkinson’s nurses, we go to the wards to review patients. When we do that we talk to the nurse that’s looking after the patient and ask if they understand what the icon means. Do they understand that Parkinson’s medications are timely because of the way that medications are delivered and the half life of medications? It doesn't take long to remind someone of that because they probably never had training on this through their nursing career.

If you explain to a nurse that if they give medications on time their job will be easier because that patient can take themselves to the toilet, that is improving things for patients but also improving things for nurses!

Robert: We educated each group with the reasons why we were doing this and how beneficial it could be to our patients, who are central in this. When people understood that I would say we had almost complete acceptance.

Nick: Yes, when 1 or 2 people buy into the idea and start to improve their practice, then the numbers go up and they see that they are improving something. And that is when you start to see other people going along with it as well.

Do you have any advice for other hospital teams on how to gain support for ePrescribing to be used in their organisation?

Nick: Use our data as an evidence base. It shows that there can be a change. In our case, it wasn’t a fast change because we had to create the systems but hopefully, that will be different with you and it can be implemented more quickly, in a controlled manner.

Electronic prescribing will be everywhere eventually. You can use this evidence to show why electronic prescribing should come earlier.

Explain that this did not cost the NHS any money. There is no ongoing cost to the NHS because this system is running in the background and the whiteboards were already there.

Robert: It's a great way of improving patient care and it’s free. It’s not so much when you’re doing it, why are you not already doing it? Ask the folk who are the most important: the patients.


What can teams that don’t have ePrescribing yet do to improve the delivery of time critical Parkinson’s medications?

Nick: Go back to basics, as part of your ward handover meetings at the end and beginning of a shift discuss that the person’s medications are due in a timely manner. Make the timings clear in your ward handover or your SBAR communication sheet.

Improve access to Parkinson’s medications, especially out of hours. We improved the emergency cupboards and created emergency stores on wards in smaller hospitals. Now we don’t have every drug but we do have smaller versions of drugs such as ropinirole 2mg. This means that we have medication available on the wards if someone comes into hospital and doesn’t have their medication with them.  

We also worked on the local intranet. Now staff can go into the pharmacy on the intranet, type in a drug and it will tell them which ward has it. This means that they can go to that ward and get a small supply if the emergency cupboard does not have the drug that the patient needs. 

What have you learned through doing this work?

Nick: Don’t panic every time you look at the daily report and a patient got their medication late. Be realistic that you can’t fix everything.

I hope I’ve learned to be constructive when I’m talking to people and support the wards. There are so many people that have come along with us, ward staff, ward managers, nurses, pharmacy staff, digital services, patients, and relatives. They are very busy but we have proved that we can make a difference, even on our busiest wards.

Robert: The system isn’t a panacea for poor care. Good care is enhanced by it and it will show up bad care because statistically, you cannot hide from it. But that is not necessarily a bad thing if you then use it to improve patient care.

The patients on the ward know how important it is to get their medications on time. Knowing that there is a system in place gives them the reassurance that they are going to get their medications on time. This increases patient trust and helps their patient journey.