Dosing omissions among medical patients in a hospital electronic prescribing and medicine administration (HEPMA) system

Abstract

Background Omitted doses are among the most common errors of medication errors in hospital. It is a need to identify the frequency of omitted doses and reasons for these to try to prevent them in the future. It is important to ensure all medication is available on the ward when needed and this can be evaluated by looking at different medicines management systems.

Aim and objectives To identify recorded reasons for dosing omissions and evaluate the clinical significance of the omissions at individual patient level using an expert group of four clinical pharmacists. Describe the different medicines management systems by using process maps and compare the findings.

Methods Reasons for dose omissions were recorded for several weeks in three different wards. Patients that had omissions recorded as Unavailable medicine were asked to take part in the study, and the clinical significance of these omissions was evaluated by an expert group. A suggestion for a guideline for nurses on what medicines that not should be omitted was developed by using results from this expert group meeting.

Results A comparison of the three wards showed no significant differences in numbers of unavailable medicines, but other reasons turned out to be different. Of 74 cases of omissions presented to an expert group 21 was evaluated to category 2; Medicines that could cause major disturbance in symptom control and one in category 3; Major treat to stability of patients condition.

Conclusion Omissions occur in different settings and can cause potential harm for patients. It is important to ensure that all medication is on ward when needed to avoid these types of omissions. The study identified that it is room for improvement in all three wards, but more and longer studies need to be carried out to be more conclusive in which changes that must me done.