Omitted Medication Doses: Frequency and Severity

Aims: To determine the number of omitted medication doses for hospital inpatients, identify the reasons and assess their severity. Method: The study involved intensive drug chart surveillance over a period of 5 days in two wards that included a wide range of medical and surgical specialties of a metropolitan teaching hospital. Inpatients receiving regular or once‐only medication for at least 5 days were monitored. A multidisciplinary committee assessed the severity of the omitted doses on a visual analogue scale of 0 to 10, where 0 is no potential harm to the patient and 10 is the potential for death. Results: Drug charts for 67 inpatients were audited. A total of 4887 doses were prescribed of which 369 (7 .6%) were recorded as dose omissions. In 273 of the 369 (74%) omitted doses, there were documented reasons for omission. 120 of the 369 doses omitted were scored for severity, with 86% (103/120) of these considered to have placed the patients at some risk of harm. No omitted doses were rated above 7 in severity. Conclusion: This study identified a substantial number of doses omitted, and a significant proportion of these were for no clear reason. The majority of the omitted doses were considered to have a potentially negative effect on the patient. Greater awareness of the extent of this problem has facilitated a collaborative effort, led by pharmacists, to improve the medication administration system.