Medicine doses are often omitted or delayed in hospital for a variety of reasons. While these events may not seem serious, for some critical medicines or conditions (such as patients with sepsis or those with pulmonary embolisms) delays or omissions can cause serious harm or death.
Between September 2006 and June 2009, the NPSA received reports of 27 deaths, 68 severe harms and 21,383 other patient safety incidents relating to omitted or delayed medicines.
Further work is needed in the NHS to address this as it is an important patient safety issue.
All organisations in the NHS and independent sector who admit patients for in-patient treatment are asked to:
1. identify a list of critical medicines where timeliness of administration is crucial. This list should include anti-infectives, anticoagulants, insulin, resuscitation medicines and medicines for Parkinson’s disease, and other medicines identified locally;
2. ensure medicine management procedures include guidance on the importance of prescribing, supplying and administering critical medicines, timeliness issues and what to do when a medicine has been omitted or delayed;
3. review and, where necessary, make changes to systems for the supply of urgent medicines within and out-of-hours to minimise risks;
4. review incident reports regularly and carry out an annual audit of omitted and delayed critical medicines. Ensure that system improvements to reduce harms from omitted and delayed medicines are made. This information should be included in the organisations annual medication safety report;
5. make all staff aware (by wide distribution of this RRR) that omission or delay of critical medicines, for inpatients or on discharge from hospital, are patient safety incidents and should be reported.