Download Medication Safety Alert - missed doses

Safe Medicines Practice Group
Medication Safety Alert 2
MISSED DOSES - the how’s, the whys and the what’s
We felt it timely to re-issue this alert as missed doses continues to be one of the common themes in
the Datix reports of medication incidents. Although this is usually classed as an administration
error, the causes may occur at any stage in the multi-disciplinary medication process. Risk
management needs to be built in at every step. It may occur for outpatients or inpatients and is
relevant to all Service Delivery Groups. The majority of missed or delayed doses are not harmful
but there may be potentially serious consequences. This alert looks at how doses are missed, why
it is important and what we can do to reduce these incidents.
How does it happen? Causes can be related to systems, documentation, personnel and
environment
Poorly hand-written or incomplete prescriptionShort courses section not checked on each
medication roundItem not transferred to new prescriptionPatient off the ward at routine medication
roundDrug history incompleteStaffing levelsPrescription card not available, in pharmacy or in
ward roundMedicine not given at usual time due to blood tests being required, then
missedInadequate or inappropriate labelsInterruptions during administration roundOmitted for a
reason but not documented, eg patient refusingMedicine not available in pharmacyMedicine not
available on the wardMedicine available but cannot be locatedMedicine supplied in unfamiliar
packagingMedicine stored in unexpected place eg tablets in fridgeGiven but not
recordedPrescribed outside of pharmacy opening hoursNon-formulary drug prescribedItem
missed from admission medication history and not prescribed.
Why is it important?  Can lead to treatment failure. This may not have immediate consequences
but can have longer-term problems. May only occur if several doses are missed.Patient may suffer
withdrawal or discontinuation symptomsMay lead to concordance issues. Patient may get the
message that to miss a few doses is not important.May lead to disruption of therapeutic drug
monitoring and cause misinterpretation of levels. Incomplete courses, return of symptoms.Side
effects may occur on recommencement of treatment.Re-titration of dose may be required.
Which medicines are of particular concern?Antibiotics. Missed doses may lead to infection
returning or not being treated. More importantly the microorganism may become resistant to
antibiotics. Oral contraceptive pill. Loss of contraceptive cover and pregnancySome
antidepressants. Discontinuation symptoms may manifest when one or more doses are missed, in
particular paroxetine and venlafaxine.Benzodiazepines. One or more missed doses may lead to
withdrawal effects. Lithium. Missed doses can lead to low serum levels and problems with level
interpretation and dose adjustments.Anticonvulsants. Missing a dose of medication may lead to a
seizure. This is more likely if several doses are missed.Preventative treatments for angina or
asthma. Missed doses may cause an angina or asthma attack.Insulin or oral hypoglycaemics. A
missed dose may have immediate effects on blood glucose levels several missed doses can lead to
poor diabetic control and longer-term consequences on healthClozapine. Missing more than 48
hours of treatment requires re-titration of the dose and consequent reduction in antipsychotic
treatment. Risperidone long acting injection and depots antipsychotics. If one dose is missed
or delayed the effects will be long term and but not necessarily immediate.
TURN OVER TO FIND OUT WHAT WE CAN DO TO REDUCE THE INCIDENCE OF MISSED DOSES
What can be done to reduce the risks? – Individuals and units
 Pharmacists should promptly clarify unclear or inappropriate prescriptions
 The wards and units should have information about the visiting times of the
pharmacists, perhaps by means of a communication book. Visiting times must
remain consistent whenever possible.
 Prescription cards should be left on the ward or unit wherever possible. If the
pharmacist is due before the medication is required, wait for them to come
rather than sending the card to pharmacy. Aim for the chart to travel as little as
possible (this helps prevent them getting lost as well).
 Units may wish to review conventional method of storage eg types of trolley
used.
 Safe and secure handling of medication should be part of the induction and CPD
of all levels of staff who handle medication or prescriptions.
 Pharmacy should indicate on the prescription whether an item is stock (S) on the
unit or dispensed individual for the service user, termed non-stock (NS) and
initial and date to show if an item is available on the ward.
 The person administering the medication must confirm with the prescriber or the
pharmacist any prescription that is unclear.
 The person administering the medication must document the administration,
using the appropriate code if medicines are not administered for a reason.
 If you find it is not possible to administer the medication at the routine round eg if
the service user is off the ward it is your responsibility to follow this up and
ensure it is given or otherwise document the reasons for not giving.
 Store medication in an agreed and logical order in the cupboards and the
trolleys. Consider labelling the shelves and doors.
 Ensure supplies are put away promptly and correctly on delivery.
 Ensure medication no longer required is removed from the trolley.
 If appropriate the pharmacy can “ring when ready” so that charts and medication
do not sit in pigeonholes awaiting delivery when they are needed on the ward.
 If an item is not available when you come to administer it out of pharmacy
opening hours ensure this is followed up by the following shift or leave a
message for the pharmacy.
 If a critical medicine is not available this should be acted on immediately,
if out of hours- by using patient’s own medicines, accessing the
emergency cupboard or on call pharmacist.
 If you are taking a medication history on admission consider all sources of
information, service user, their GP or their own medication. The community
pharmacist can usually tell you if something has been dispensed recently ie is
still current.
 Read all sections of the chart on each administration round. Something new
may have been written up and not handed over to you.
Start date – treatment will start at the next administration round that day.
Treatment will continue until midnight on the stated stop date.
What can be done to reduce the risk? – Organisation
The Trust wide Medicines Code is available on the intranet and all wards have
copiesTraining in medicines management for staffRe-consider conventional methods of
supply, for example using patients’ own medication or the one- stop dispensing service
used in some areasSupply wherever possible in manufacturers original packs which
makes things more recognisable however these have contributed to dose and drug
selection errors.
Safe Medicines Practice Group – September 2012 Originally produced April 2005
Would you like to join us? We meet every two months at various locations. Please contact Kate Dewhirst,
Deputy Chief Pharmacist, email [email protected] for details.