Characterization of Electronic Missing Medication Requests to Identify Medication-Use System Vulnerabilities and...

Area of Science:

• Healthcare quality improvement
• Health informatics
• Medication safety systems

Background:

• Missing medication requests (MMRs) are frequent in inpatient settings.
• They may indicate vulnerabilities in medication distribution and communication.

Purpose of the Study:

• To characterize electronic health record (EHR)-generated MMRs.
• To identify the origin, timing, and reasons for MMRs.
• To inform targeted interventions for improving medication management.

Main Methods:

• Retrospective review of MMRs submitted over 30 days at a community teaching hospital.
• Analysis of message origin, time of submission, and request type.
• Post-intervention assessment of aggregate message volume.

Main Results:

• 13,915 MMRs were submitted, averaging ~20 per hour.
• Requests peaked around nursing shift changes (0800, 2000) and in high-acuity areas.
• Top reasons included continuous infusion redispense, dose requests despite dispense, and cart-fill issues.
• Workflow interventions reduced aggregate message volume by 14.7%.

Conclusions:

• High-volume MMRs highlight medication-use system vulnerabilities.
• Characterizing MMRs aids in prioritizing interventions like infusion standardization and workflow optimization.
• Targeted interventions can reduce MMRs and improve medication management efficiency.