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Summary
Missed medication doses due to unavailability of the oral route caused significant patient harm and deaths. Interventions are crucial to prevent these medication safety incidents.
Area of Science:
- Patient safety
- Medication administration
- Healthcare quality improvement
Background:
- Over 21,000 patient safety incidents, including fatalities, resulted from missed or delayed medications between 2006 and 2009.
- A significant number of medication safety incidents are linked to the unavailability of the oral route for administration.
Purpose of the Study:
- To quantify medication incidents linked to the oral route being unavailable from 2005 to 2013.
- To identify areas for practice improvement in medication safety.
Main Methods:
- Searched the National Reporting and Learning System for omitted and delayed medication incidents (2005-2013).
- Filtered searches for incidents where the oral route was unavailable.
- Conducted qualitative analysis of 200 incident reports to identify common themes.
Main Results:
- 1,882 incidents met the search criteria, predominantly in hospital settings.
- Six deaths and 581 harms were reported.
- Patients who were nil by mouth represented the largest group; anti-epileptic medications were most frequently omitted (17%).
Conclusions:
- The reported number of incidents likely underestimates the true prevalence of missed oral doses when the oral route is unavailable.
- Proactive interventions are necessary to mitigate patient harm and improve medication safety.