Minimising harm from missed drug doses

The National Patient Safety Agency reported that more than 21,000 patient-safety incidents, including death, occurred between September 2006 and June 2009 as a result of missed or delayed medication doses.

To identify the number of incidents reported between 2005 and 2013 associated with the oral route not being available. Find ways to improve practice.

The National Reporting and Learning System was searched for medication incidents categorised as omitted and delayed from 1 January 2005 until 31 December 2013. Search terms were used to filter for incidents associated with the oral route not being available. Qualitative analysis of 200 incident reports identified common themes.

In total 1,882 incidents met the search criteria, the majority in hospitals. There were six deaths and 581 harms. The largest number of reports concerned patients who were nil by mouth. Analysis of the medicines described found that the most commonly omitted medicine (17%) was anti-epileptic medication.

It is estimated that the actual prevalence of omitted doses where the oral route was not available is greater than this paper describes.

Positive intervention is needed in this area to reduce harm to patients.