Clinical audit of dosing omissions among surgical patients in a hospital electronic prescribing and medicine administration(HEPMA) system

Abstract

Abstract

Background: Medication errors are a national concern, and even small changes can make a real difference in reducing harm to patients. Dose omissions are one of the medication errors causing harm, and it is a recommendation for NHS organisations to periodically audit all omissions to help target where improvements can be performed to prevent these errors.

Aim and objectives: The aim of the project was to collect numbers of frequency, reasons and the relative risk of causing harm to patients for dose omissions in surgical settings at The Ayr Hospital. From the results the aim was also to create guidelines to help inform ward staff about medicines that should not be omitted in the peri-operative period.

Methods: A prospective study was performed in a hospital electronic prescribing and medicine administration (HEPMA) system to study dose omission patterns for a period of three weeks at two surgical wards. Clinical information was collected from patients suffering from dose omissions that were included in the study by giving their consent. An expert group of 4 pharmacists evaluated the omitted doses after a new assessment for scoring clinical significance, and guidelines were developed from the findings.

Results: The total numbers of dose omissions in both settings were10.1% and 6.0%, and there were several differences between the two settings. Of all omitted doses evaluated for clinical significance 41.2% were scored as possible to cause a disturbance to the patient's symptom control in some degree.

Discussion: The different outcomes at the two wards can possibly be explained by the frequency of surgeries performed in each ward, turnover of patients and use of different medicine supply systems. Scoring of clinical significance of omissions would possibly vary by the selection of patients because there are many important individual aspects.

Conclusion: Dose omissions are common and many of them are possible to cause disturbance to patients symptom control when omitted in the peri-operative period.