Analysis of missing medication episodes in a unit dose system

The unit dose drug distribution system at The Buffalo General Hospital in Buffalo, New York, was evaluated by an analysis of cases in which doses of medication were missing from the unit dose administration cart. When a dose was missing, the medication administration nurse reported the occurrence to the pharmacy. When time permitted, the cause of the missing dose was determined and recorded. Thirty causes for missing doses are cited. The causes were found to arise from misuse of the unit dose system by nurses, misunderstandings between the Nursery and Pharmacy Departments, or from oversights on the part of nurses or pharmacy personnel. Missing doses can be prevented in the future by instructing nurses in the use of the system, improving communication between the Departments of Pharmacy and Nursing concerning the needs of the patients, and being aware of mistakes that can occur so care can be taken to prevent them in both departments.