Decrease the Numbers of Inappropriate
Omitted Medication Doses
Margaret Davison Senior Nurse Quality, Patient Safety and Patient Pathways, Caroline Speedy Assistant Clinical Service Manager, Helen Bell
Governance Pharmacist, Rachel McFarland Ward Sister, Debbie Scott Registered Nurse, Mae Malto Registered Nurse, Roxy Parker Registered Nurse.
The Northern Ireland Nursing KPI (Key Performance Indicator)
audits the number of blanks only on the Medication
Prescription and Administration Record .
The most recent Northern Trust performance for this KPI is
98% which would indicate that omitted doses are not an
issue. The number of Datix reports is also high, which reflects
the extent of the problem.
Anecdotally the evidence would support this.
Medications can be omitted for a number of reasons and this
is not reflected in the regional KPI.
↓In numbers of inappropriate omitted medication doses.
↓Length of stay (LOS).
↑Treatment in Delirium using the Delirium pathway.
↑Earlier notification to Medical staff with medical review.
Omitted medication baseline monitoring (5 July 2019)
66% omitted medication (22/33 patients).
Omitted medication monitoring no. 2 ( 19 August 2019)
39% omitted medication (13/33 patients).
Omitted medication monitoring no.3 (19 September 2019)
12% omitted medications (4/33 patients).
Process
• Introduce a regular omitted dose audit programme in Northern Trust
• Corporate Nursing to feed into review of regional omitted dose KPI
• Linking with nursing education to develop an approach to deliver
improvements
Staff Education and Training for Nursing, Medical and Pharmacy Staff
• Raise awareness of critical medications
• Roll out the Medication Safety Thermometer across Trust
• Full rollout of delirium pathway
• Raising awareness of the need to review refused doses for alternative
routes regularly
Communication
• Highlighting omitted doses at nursing handover and safety brief
• Prioritisation for the ordering and delivery of omitted/critical medicines
Why is this important?
Outcome measures
Learning and next steps
Aim
To decrease the number of
inappropriate omitted medication
doses in ward A3 by 20% from
baseline by October 2019
Overall decrease 54%
What has it achieved?
What are we doing and why?
Insert Trust Logo
In February 2010 the NPSA issued Rapid Response Report 009
Reducing Harm from omitted and delayed medicines in
hospital.
• Improve patients' physical and mental health
• Reduce unnecessary harm resulting from medication errors
and give nurses more support in medication administration
• Developing systems to improve and audit the timeliness of
administration including omitted medication.
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Number of inappropriate omissions for 33 patients in
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Run Chart to show percentage of inappropriate
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omitted medication
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Number of inappropriate omisstions for 33 patients
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Median
Number of omissions
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