Non-therapeutic omission of medications in acutely ill patients

To examine documentation of medication administration in medical and surgical patients.

(1) Determine the point prevalence of non-therapeutic medication omissions; (2) identify documented reasons for non-therapeutic medication omissions; (3) examine the relationship between length of stay and medication omissions; and (4) explore the impact of outlier status (e.g. medical patients managed on surgical wards) on medication administration.

Acutely ill patients are particularly sensitive to health care errors. We previously identified a 26% rate of non-therapeutic medication omissions in patients admitted unexpectedly to intensive care unit (ICU) from medical and surgical wards.

A point prevalence survey of 162 medical and surgical patients across four sites in the South West of England.

Data collected included: all instances of, and reasons for, non-therapeutic medication omission. We also recorded whether the patient was an 'outlier' and examined nursing documentation where no reason for medication omission was given on the drug chart.

The number of patients who missed at least one medication was high across all sites (n = 129/162; 79.6%, range 60-88%), with a total of 1077 doses omitted. Patients who were outliers (e.g. surgical patients on a medical ward) were more likely to miss medications (100% versus 74%, p < 0.001). The most common missed medications were analgesia and anti-inflammatory drugs (28%, 299/1077); 203 of these were due to patient refusal.

The extent of medications omitted for non-therapeutic reasons in medical and surgical patients is of concern. None were recorded as an adverse drug event; however, the extent of omitted or refused medications suggests the need for a review of prescribing and drug administration processes. These findings have important implications for the role of ICU outreach and liaison services, for example, including medication management in the monitoring of patients pre/post-ICU admission and support/education provided for ward staff.

Detailed analysis of medication records suggests a number of areas of medication administration that would benefit from review.