June 2011
Safeline00060 omitted and delayed doses
Omitted and Delayed Doses
Safeline00060 omitted and delayed doses
Background
Medicine doses are often omitted or delayed in hospital for a variety of reasons. For some critical medicines or conditions, such as patients with sepsis or those with pulmonary embolisms, delays or omissions can cause serious harm or death.
Patient Safety Incidents
Between September 2006 and June 2009, the NPSA received reports of 27 deaths, 68 severe harms and 21,383 other patient safety incidents relating to omitted or delayed medicines. The true rate of harm may be much higher, as these events are often not reported.
NPSA Action Required
- Identify a list of critical medicines where timeliness of administration is crucial.
- Medicine management procedures should include guidance on the importance of prescribing, supplying and administering critical medicines, timeliness issues and what to do when a medicine has been omitted or delayed.
- Review and, where necessary, make changes to systems for the supply of critical medicines within and out-of-hours to minimise risks.
- Review incident reports and carry out an annual audit of omitted and delayed critical medicines. Ensure that system improvements to reduce harm from omitted and delayed medicines are made.
- Make staff aware that omission or delay of critical medicines, for inpatients or on discharge from hospital, are patient safety incidents and should be reported.
Action at Aintree
Definitions of omission and delay are:
- An omitted dose is a failure to administer a dose before the next scheduled dose is due OR a failure to prescribe a drug in a timely manner
- A delayed dose is administration of a drug
2 hours or more after the time the dose is prescribed
An omitted or delayed dose of a life-threatening or critical drug is a patient safety incident and should be reported viaDATIX.
The Drugs and Therapeutics Committee have agreed the following list ofmedicines for the trust:
Life-threatening medicinesto be given within ONE hour of intended prescription time
First parenteral dose of:
- Anti-infectives (antibiotics, antifungals, antivirals)
- Anticoagulants (including first oral dose of rivaroxaban) and thrombolytics
- Anti-epileptics (including benzodiazepines)
- Anti-arrhythmics
- Resuscitation Drugs (including colloid and crystalloid IV fluids)
All insulin (IV, SC) in relation to prescribed time and timing of meals/feed
Critical medicinesto be given within TWO hours of intended prescription time
- Any parenteral drugs (IV, SC, IM)
- Oral chemotherapy
- Oral anti-infectives (antibiotics, antifungals, antivirals)
- Parkinson’s disease medications
- Oral anticoagulants
- Any oral ‘STAT’
- Anti-epileptics (PO, PR)
- Fluid resuscitation (not included in abovelist)
If a life-threatening or critical medicine or any ‘urgent medication’ is unavailable on ward. You MUST:
- during pharmacy opening hours,bleep your ward pharmacist or obtaindirectly from pharmacy
- out-of-hours, use the pharmacy night-store, obtain from another ward or contact the on-call pharmacist via switchboard.
A multidisciplinary task and finish group has been set-up to further look at the issue of omitted and delayed medicines and take further action to address this problem.
Contacting Medicines Information
You can reach us through your ward pharmacistor contact us direct on ext 3208.
Sue Fryer, Nicola Durnin
Medicines Information Pharmacists
The information in this bulletin was current at the time of publication.
Safeline00060 omitted and delayed doses