Aging population and rise in automation: human-machine interface (HMI) needs closer look

The Safety In­ves­ti­ga­tion Au­thor­ity has com­pleted an in­ves­ti­ga­tion into a med­ica­tion er­ror that oc­curred in Sa­takunta in the spring of 2023, when one med­i­cine was omit­ted from a home-based pa­tien­t’s pre­scrip­tion.

One of the medicines prescribed for the patient was omitted when the order was sent to the dose-dispensing unit. Neither the pharmacy nor the home-care team noticed the omission. Just under two weeks later, the patient’s health took a turn for the worse. The patient was taken to a hospital and died there two days later. The forensic investigation into the cause of death was unable to establish a link between the omitted medicine and the patient’s death.

 ‘Although the forensic investigation into the cause of death was unable to establish a link between the medicine and the patient’s death, this case gives us important insight into a significant social phenomenon and medication safety in general. The percentage of elderly people in our society is rising. There are approximately 600,000 people aged 75 years and older in Finland, and the percentage of over-75-year-olds being prescribed multiple medications is growing every year. Moreover, wellbeing services counties have decided that patients receiving regular home care should, as a rule, be included in the automated dose-dispensing scheme. There are just under 600 pharmacies that use automated dose dispensing. More than 100,000 patients are included in the dose-dispensing scheme, and the number is growing by between 12 and 15 per cent each year and will therefore continue to rise in the future’, says Investigator-in-Charge Hanna Tiirinki.

Tiirinki adds: ‘The simple fact is that the proportion of elderly people in the population is rising. More and more over-75-year-olds receive their medications by means of automated dose dispensing. There are several hundred pharmacies that use automated dose dispensing, and their customers represent a significant proportion of the population – a proportion that is only set to increase in the future.’

 The investigation conducted by the Safety Investigation Authority revealed that automated dose dispensing – although generally considered to improve medication safety – nevertheless comes with many risks that relate to the various stages of the process, such as omissions in prescriptions, inconsistent practices, information systems and coordination between operators.

 ‘In this case, the patient’s suitability for automated dose dispensing had not been reviewed at any point, even though there were reasons to stop dose dispensing. The threshold for removing a patient from the dose-dispensing scheme is also too high, even when it is clear that the patient is not suitable for the scheme due to, for example, their medication. The practice of pharmacies to make “rush orders” also increases the risk of medication errors – individual medicines are easily omitted. Pharmacies are part of the health-care system and must be examined in that context. In this case, the system of pharmacy oversight and supervision failed to stop a high-risk practice – and this is one of the issues that our recommendations address. On the other hand, the system of home-care oversight and supervision also failed in this case’, Investigator-in-Charge Tiirinki explains.

‘I would like to emphasise that automated dose dispensing is generally considered to improve medication safety. We just need to identify the procedures and frameworks to translate the theory into practice, and both man and machine – the dispensing system, in this case – are often critical in this respect. There is also room for improvement in the self-regulation of pharmacies’, Tiirinki adds.

The Safety Investigation Authority is issuing three recommendations that are aimed at the Ministry of Social Affairs and Health. The recommendations relate to weaknesses in legislation and the information systems that are currently used in dose dispensing, more effective sharing of patient safety incident reports concerning medication errors between pharmacies and wellbeing services counties, and revision of the Guide on Good Practices in Patient-specific Dispensing of Medication in collaboration with other authorities. The Finnish Medicines Agency is being urged to ensure that pharmacies adopt better self-regulation procedures to promote medication safety.