A method for monitoring medication omission error rates

A study was conducted of the number of doses omitted on eight patient care units in a hospital which employs a decentralized unit dose system. Omitted doses were doses of drugs that were returned to the pharmacy and that, as subsequently determined, should have been administered to patients. The number of omitted doses was 0.048 per patient day. The number of omitted doses per patient day varied among the patient care units. The results were reported to the Medication Practices Review Committee, a subcommittee of the Pharmacy & Therapeutics Committee. Subsequently, educational efforts by the Departments of Nursing and Pharmacy were directed towards reducing the omitted-dose rate. The study was repeated five months later. The number of omitted doses had fallen to 0.011 doses per day, a significant difference from the previous study. All patient care units but one had significantly fewer omitted doses, with the other patient care unit showing no change. This study showed that the rate of omitted doses can be estimated without the use of trained observers. Additionally, this method can be used to determine the changes in the omitted dose rate within a hospital.