Download Omitted and Delayed Medicines

Specialist Pharmacy Service
Medicines Use and Safety
Omitted and Delayed Medicines
A collaborative audit of omitted and delayed
anti-microbial doses in acute, community and
mental health settings
Jane Hough and Jane Nicholls
Medicines Use and Safety Division
NHS Specialist Pharmacy Service
May 2012 and reviewed May 2015
© Specialist Pharmacy Services
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Medicines Use and Safety
A collaborative audit of omitted and delayed anti-microbial doses, in
acute, community and mental health care settings
Executive Summary
1.
19,655 patients from 54 trusts were reviewed over a 24 hour period. 6062 patients were
prescribed parenteral or enteral antimicrobials and 21,825 doses representing 8748
antimicrobial prescriptions were audited.
2.
The audit identified an average omission rate of 5.3% (1151/21825) for prescribed antimicrobial
doses. 13.2% (802/6062) of audited patients missed at least one dose of a prescribed
antimicrobial.
3.
The existence of any one of the following made a dose twice as likely to be missed
 First dose
 First dose not written up as a “stat” dose
 Antimicrobial not held as ward stock
4.
In the 45 acute trusts no reason was recorded for 29% of the omissions, an ‘other’ reason for
26% and antimicrobial ‘not available’ for 19%. Refusing a dose and no route of administration
available both reported 12% of omissions and patient away from the ward only 3% of omissions.
5.
19% of the doses recorded as being ‘unavailable’ were actually available on the ward at the time
the dose was due to be administered.
6.
When followed up by data collectors, doses had been given but not signed for in at least 29% of
the cases where the administration records had been left blank.
7.
6.3% (565/8923) of doses were overdue at the time the audit took place. 7.7% (467/6062)
patients were overdue an antimicrobial dose at the time of the audit.
8.
Electronic prescribing sites reported the same omission rate as traditional prescribing sites but
they had a higher proportion of delayed doses (16% v 5.4%).
9.
A much smaller number of community health and mental health patients were audited compared
to acute trusts and fewer antimicrobials were prescribed. 16.7% of mental health patients
missed doses and more often through non-availability than in acute trusts. However mental
health patients were found not to refuse doses more frequently than acute trust patients.
10. There were differences in omission rates and reasons for omission between the acute trust care
areas; some care areas with high omission rates had small data sets. Omission rates were
relatively high for care of the elderly patients and low for critical care and paediatric patients.
11. The issues influencing delayed and omitted antimicrobial doses are multifactorial, complex and
require multi-disciplinary solutions. Trusts should identify specific issues locally and develop
solutions with nursing and medical colleagues to ensure prescribing is clear and takes account
of routes of administration available and that supply is slick and intuitive and nursing staff
understand the importance of administering critical medicines on time and are helped to
prioritise medicines within their other competing tasks. In general documentation needs
improving and traditional methods of restricting access to antimicrobials needs to be reviewed.
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Recommendations to Trusts
Trusts are recommended to review their data locally and to compare to the overall results to identify
their areas of good practice and those with room for improvement.
The overall results suggest trusts should in general:
1. Raise awareness of the importance of prescribing and administering critical medicines in a
timely manner amongst all healthcare professionals and ensure there are clear lines of
responsibility
2. Review supply processes particularly for first doses. Supply processes need multi-professional
input, need to be instinctive and take account of current situation e.g. outliers, accessing a
remote Emergency Drug Cupboard
3. Traditional methods of controlling access to restricted anti-microbials such as ward stock lists
may need to be reviewed
4. Adopt the Department of Health’s Start Smart and Focus approach
5. Put systems in place to help nursing staff locate antimicrobials on the ward area by e.g. using
productive ward techniques, aide memoirs
6. Ensure that omitted doses are followed up – particularly those recorded as “not available”; as
these may be on the ward and the nurse has been unable to locate
7. Work with nursing colleagues around poor documentation including “blanks” which is covered in
Nursing and Midwifery Council (NMC) Standards for Medicines Management (Standard 8 point
2.10)
8. Be aware that solutions for one care area may not be as successful in another care area so
engagement with nursing staff and understanding the difficulties they face is key (particularly
competing priorities; competence to administer and familiarity with the medicine)
9. Encourage medical staff to communicate (including to the patient) when prescribing an
antimicrobial (or any other medicines on local critical medicines lists); ensuring the prescription
is appropriate for the route(s) of administration that are available and that it is legible (and
includes indication and duration where necessary)
10. Multiple refusals of doses should be reported to prescribers for a review of the prescription
11. Revisit how well allergy status is documented particularly where policy states this needs to be
recorded before doses (especially penicillin containing antimicrobials) are given
12. Revisit Nil By Mouth policies to ensure all staff give consistent advice
13. Provide guidance on timings of future doses where administration times have become out of
synch with prescribed times
14. Share audit results and good practice
15. Embed delayed and omitted doses as an organisational responsibility
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A collaborative audit of omitted and delayed anti-microbial doses, in
acute, community and mental health care settings
1.
Aim
The aim of the collaborative audit was to gather data which would help to quantify the extent of omitted
and delayed enteral and parenteral anti-microbial doses and the range of reasons for these in all care
settings; which could then be used to target areas for improvement.
2.
Objectives:

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3.
To quantify the number of omitted and delayed doses of antimicrobials.
To collect information on the reasons for doses being omitted
To attempt to validate “not available” & “blank administration record” reasons
To examine the differences between first dose omissions and those of other doses.
Background
The National Patient Safety Agency (NPSA) issued a Rapid Response Report on Reducing harm from
omitted and delayed medicines in hospital (RRR009) in February 20101. Between September 2006 and
June 2009 the NPSA received reports of 27 deaths, 68 severe harms and 21,383 other patient incidents
relating to omitted or delayed medicines. Of the 95 most serious incidents, 31 involved anti-infectives.
th
The RRR lists a number of actions organisations needed to complete by 24 February 2011.
One action was for each organisation to identify a list of critical medicines where timeliness of
administration is crucial. The list should include anti-infectives amongst other medicines. Another action
was to carry out an annual audit of omitted and delayed critical medicines and to ensure that system
improvements to reduce harm from omitted and delayed medicines are made.
A multicentre collaborative point prevalence audit was designed to allow organisations to benchmark
themselves; to identify specific areas of weakness in their current practices and use these to inform
system improvements. Successes in areas of good practice would be shared to support those doing less
well. Trusts would be able to use or adapt the methodology to undertake repeat audits in the future to
measure improvement.
Because a collaborative audit on delayed and omitted doses of all prescribed medicines would have been
unwieldy it was decided to focus the audit on antimicrobials which are prescribed in all care settings and
all sectors of care and the NPSA had recommended should appear on organisations lists of critical
medicines.
4. Methodology
Trusts from the four original SHAs (East of England, London, South Central and South East Coast) in the
East and South East England geography were invited to participate in the collaborative audit. 45 acute
trusts, four community health and five mental health trusts submitted data. Participating trusts are listed in
Appendix A.
The point prevalence audit was carried out over one 24 hour period on a day of choice of the participating
Trusts in December 2010. Mondays were avoided to mitigate against variations arising from different
supply arrangements at weekends; and Fridays were generally too busy a day for data collection.
On the nominated day antimicrobials that had been prescribed to be administered over the preceding 24
hour period were reviewed and data was collected on the form provided (this had previously been
piloted). Detailed guidance was also provided on data to include and how to record it. Data collection
forms and guidance notes can be found in Appendix B.
Omitted doses were allocated to one of six categories describing the reason for omission as recorded on
the drug chart.
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Categories used to describe reasons for omission
Reason dose omitted
Away
Blank
Not available
No route
Other
Refused
Explanation
The patient was away from the ward at the time the antimicrobial dose was due
Nothing had been recorded in the administration box by the nurse
The antimicrobial was reported on the drug chart as not being available on the
ward for administration
The prescribed route of administration was not available for use e.g. no
intravenous access
Reason for omission was not covered by any of the other categories but an
explanation had been recorded e.g. NBM
Patient refused to take the dose
The data collectors attempted to follow up the reasons for omissions recorded as “not available” and
“blank”; by looking for the unavailable antimicrobial on the ward and estimating if it would have been there
at the time the dose was due and for blanks discussing with the nurse (if he/she was on duty at the time
of data collection) whether he/she had given the dose but had forgotten to sign the administration record.
Local audit co-ordinators ensured consistency of data collection and entered data onto the organisation’s
master spread sheet. This had been populated with embedded formula to provide some initial local data
that could be used to help close the NPSA Rapid Response.
Master spread sheets from the participating organisations were returned centrally for collation, review of
data and data cleansing prior to further analysis.
Statistical analysis used the Chi Square test where appropriate.
5.
Definitions used in the audit were:
Omitted Dose
Delayed Dose
First Dose
Last Dose
Stat Dose
Restricted
Antimicrobial
Ward Stock
6.
Definition
A dose that had not been given before the next dose was due
A dose that was overdue at the time of the audit – this was measured in hours
(underestimating the actual duration of the delay but identifying the number of doses
that had been delayed)
The first dose of a course of antimicrobial therapy. Including those doses prescribed
as stat doses.
The last dose prescribed to be administered during the 24 hours of data collection
(not necessarily the last dose of a course)
A single dose prescribed to be given as a “one-off”; often at a specific time for
example as part of surgical prophylaxis. These may be prescribed in a specific
section of a drug chart.
An antimicrobial that is reserved within a given organisation because of its spectrum
of activity, resistance patterns or cost; or because only a specific clinical area uses it.
Routinely used antimicrobials that are held as routine stock on a ward and supplied to
a ward against a stock list rather than an individual prescription.
Results
6.1
Demographics and Overview of Omissions and Delays
Overview of all data
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45 acute trusts, four community health & five mental health trusts participated
6062 patients from the 54 trusts were prescribed 21,825 doses of antimicrobials
5.3% (1151/21825) doses were omitted
13.2% (802/6062) patients missed a dose
6.3% (565/8923) last doses were delayed
7.7% (467/6062) patients were overdue an antimicrobial dose at the time of the audit.
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6.1.1 Overview for Acute Trusts
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17,470 patients from 45 acute trusts were audited
33.9% (5899) patients were prescribed 21390 doses of 8748 antimicrobials.
The median number of doses prescribed per patient was 3 (range 1 to 7).
56.6% (12106) of doses prescribed were parenteral.
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5.2% (1120/21390) of prescribed doses were omitted
Patients missed between 1 and 4 prescribed doses with a median of one.
13.2% (781/5899) patients missed at least one dose ie 1 in 7 patients
The rate of omissions ranged from 0% in one small trust to 9.7%; with 1.4% as the lowest rate in a
trust reporting omissions.
 Trusts ranged between none and 100% of omitted doses being first doses.
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15.2 % (3261/21390) of prescribed doses were first doses
9.6% (313/3261) of prescribed first doses were omitted
27.9% (313/1120) of omitted doses were first doses
10 trusts had no omitted first doses and for one trust all the first doses prescribed were omitted, for
the remaining trusts 1.7 to 42.9% of first doses were omitted.
 6.4% (562/8748) of last doses were delayed
 7.9% (465/5899) of patients (1 in 13) were overdue a dose at the time of the audit
 18% (1066/5899) of patients (1 in 6) had at least one omitted and/or delayed dose
6.1.2 Overview for Community Health Trusts
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651 patients from four community health trusts were audited
14.7% (97/651) patients were prescribed 265 doses of 109 antimicrobials.
Median number of doses prescribed was 3 (range 1 to 4)
94.5% (250/265) of prescribed doses were enteral.
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4.5% (12/265) of prescribed doses were omitted
The median number of omitted doses was one (range 1 to 2)
10.3% (10/97) of patients (1 in 10) missed at least one prescribed dose.
The rate of omissions ranged from 1.7% to 14.3% in trusts.
Only one trust omitted any first doses and these were a quarter of all the doses omitted in that trust.
 One prescribed dose was delayed by at least four hours
 11.3% (11/97) patients (1 in 9) had at least one prescribed dose omitted or delayed.
6.1.3 Overview of Mental Health Trusts
 1534 patients from five mental health trusts were audited
 66 (4.3%) were prescribed 170 oral doses of 66 antimicrobials
 Median number of doses prescribed was 3 (range 1 to 4)
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11.2% (19/170) of prescribed doses were omitted
Median number of omitted doses was 2 (range 1 to 3)
16.7% (11/66) of patients missed at least one dose
The rate of omissions ranged from 0% in one trust to 21.1%; with 2.6% as the lowest rate in a trust
reporting omissions.
 25 first doses were prescribed and 20% (5/25) of these were omitted
 Trusts ranged between 0 and 75% of omitted doses being first doses
 Two doses were delayed by at least two hours – these were prescribed for a patient who also
missed a dose.
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6.2 Omissions
All omissions were allocated to one of six reasons for omission by the data collectors as described in the
audit guidance. The categories were away, blank, not available, no route available, other and refused
(see section 4 above for definitions of these terms)
6.2.1 Acute trusts – all omitted doses
In acute trusts 5.2% (1120/21390) of prescribed doses were omitted.
The rates of omissions ranged from 0% in one small trust to 9.7% of doses prescribed; with 1.4% as
the lowest rate in a trust reporting omissions.
The three most frequently reported reasons for omission were; a “blank” administration box on the
drug chart (29%), followed by ”other” (26%) and then “not available” (19%). The least frequently cited
reason for omission was the patient being “away” from the ward (3%); whilst “no route” available and
patient “refusing” the dose were both found to be 12%. See Figure 1.
The reasons for omission of all doses and first doses are also described in table 4 on page 10.
Figure 1 Percentage of omitted doses for each reason in acute trusts
Away
Aw ay, 3%
Blank
Other, 26%
Blank, 29%
Refused
No route
Not available
Other
Not available, 19%
Refused, 12%
No route, 12%
6.2.2 Acute Trusts - Omissions by reason
More detail is given for each reason for omission in acute trusts starting with the least frequently
reported
Patient “Away” from ward was the least frequently reported reason for omission affecting 3%
(28/1120) of omitted doses in acute trusts. Patients were away from the ward eg having an
investigation, visiting the physio etc and missed a dose; that is the dose had not been administered by
the time the next dose was due.
“No route” available was recorded as the reason for omission for 12% (134/1120) of omitted doses in
acute trusts. This affected patients for whom there was eg no intravenous access or their naso-gastric
tube was blocked or had been removed.
“Refused” by the patient accounted for 12% (138/1120) of omissions. Refusal to take a dose
occurred over all the medically orientated care areas and less frequently in critical care, surgical areas
and maternity.
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An “Other” reason was recorded for 26% (291/1120) of doses not administered; these were reasons
not covered by the other 5 categories; this could be because a blood level was awaited, the prescribed
requested the medicine held or there was no allergy status documented. Many of these omissions
could be considered intentional.
Leaving the administration box entirely “blank” was the most frequently reported 29% (320/1120)
reason for omitting doses. The nurse leaving the administration box blank implied that the dose had
not been given.
In 20.9% (67/320) of occurrences where the administration box had been left blank; data collectors
were able to speak to the nurse who confirmed she had given the dose but had forgotten to sign the
chart. In 79% of instances the nurse was either not available to have the discussion, could not
remember if they had given the dose or confirmed they had not given the dose. Thus it is possible that
further doses had been given but not recorded suggesting 20.9% may be an underestimate of the
number doses actually given with no documentation.
“Not available” was the reason for omission recorded for 19% (209/1120) of omitted doses. It was
possible for data collectors to locate and estimate 30% (63/209) of the antimicrobials were available on
the ward at the time the dose had been prescribed to be given; but the nurse for what-ever reason had
not been able to find it.
6.2.3 Omissions in acute trusts perceived as being due to the method of supply of the
antimicrobials.
Antimicrobials are provided to clinical areas as a stock item where they are likely to be routinely used;
whilst agents that are not routinely used in a care area, have a resistance problem, are expensive, or
are second or third line treatment are more typically supplied against an individual prescription. A
comparison of prescribed doses and omissions of antimicrobials stocked on wards and those supplied
against individual prescriptions is shown in Table 1.
Table 1 Acute Trusts - Antimicrobial doses prescribed and omitted by type of supply
arrangement
Number (%) of doses
kept as ward stock
Number of doses prescribed
Number of doses omitted
% of doses omitted
17712 (82.8%)
777
4.4%
Number of doses (%) not stocked
and supplied as individual
prescriptions
3671 (17.3%)
343
9.3% (p<0.001)
Doses supplied on individual prescriptions were found to be omitted twice as often (9.3%) as those
routinely available as ward stock (4.4%) (p<0.001). In comparison there was no significant difference
in the rates of omission for “restricted” antimicrobials and those available for routine prescribing see
Table 2.
Table 2 Acute Trusts - Antimicrobial doses prescribed and omitted by availability status
Number of doses prescribed
Number of doses omitted
% of doses omitted
Unrestricted
antimicrobials
18100 (84.6%)
928
5.1%
Restricted antimicrobials
3290 (15.4%)
192
5.8% (p<0.1)
6.3 Community Health - Omissions by reason
Twelve doses in total were omitted in the community health setting. 4.5% (12/265) of prescribed doses
were omitted. This was a lower omission rate than for acute trusts. In one case (8%) the patient was
away from the ward; in three cases (25%) the antimicrobial was recorded on the drug chart as being not
available (the data collectors did not report being able to find any of the doses in the care area) and in 8
cases (67%) the administration box on the drug chart had been left blank by the nursing staff. In half of
these cases data collectors; were able to confirm with nurse that she had in fact given the dose but had
forgotten to record it on the drug chart. Table 3 describes these results.
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6.4. Mental Health - Omissions by reason
Nineteen doses in total were omitted in the mental health setting. 11.2% (19/170) of prescribed doses
were omitted. In one case there was a recorded “other” reason for non-administration and there were two
cases where the patients refused doses. In seven cases the administration box on the drug chart had
been left blank; the data collectors were able to confirm in two cases (28.6%) that the nurse had in fact
given the dose but had forgotten to sign the chart. For the other five cases the data collectors were either
unable to speak to the nurse responsible for administering the dose at the time of data collection or if the
nurse was available she confirmed she had not administered the dose.
A reason of non-availability was recorded for just under half (9/19) of the omitted doses. The pharmacy
staff collecting the data found two of these doses in the clinical area and estimated they would have been
available to be administered. Five of the nine doses omitted because of non-availability were first doses
of courses. These results are described in Table 3.
Table 3 Community and Mental Health Omissions by reason
Reasons for
Omission
Blank
Other
Not available
Refused
No route
Patient Away
Total
Community Health
Number of
% of omissions
omissions
8
67
0
0
3
25
0
0
0
0
1
8
12
100
Mental Health
Number of
% of omissions
omissions
7
36.8
1
5.5
9
47.4
2
10.5
0
0.0
0
0.0
19
100.0
Mental Health patients were no more likely to refuse a dose (11%) than physical health patients in an
acute setting (12%).
6.5 Acute trusts - omitted first doses
In acute trusts 15.2% (3261/21390) of doses prescribed were first doses. Of these 9.6% (313/3261) were
omitted. The reasons for omission were of similar proportion to those for all doses (see Table 4) except
for the non-availability category which was almost doubled in frequency; from 19% to 33% (p< 0.001).
807 doses were omitted and 17282 doses administered from the “rest of the course”; an omission rate of
4.45%. First doses were found to be omitted twice as frequently as doses from the rest of the course
(9.6% v 4.45% p< 0.001). This was a statistically significant difference.
Table 4 Acute Trusts - Reasons for omission of all and first doses of antimicrobials
Reason for omission
Blank
Other
Not available
Refused
No route
Patient Away
Total
All antimicrobial doses
Number
%
320
29
291
26
209
19
138
12
134
12
28
3
1120
100
First doses of antimicrobials
Number
%
77
24.6
78
25.0
103
33.0 (p< 0.001)
25
8.0
26
8.4
3
1.0
312
100.0
Reviewing omission rates of first doses for individual trusts there were ten trusts where no first doses
were omitted and in one where all of the first doses prescribed were omitted. For the remaining trusts the
percentage of first doses omitted ranged from 1.7 to 42.9%. And considering the proportion of first dose
omissions as a percentage of all omissions these covered the complete spectrum from none to 100% of
all omitted doses being first doses. The trust with 100% of omitted doses being first doses had a low
(1.4%) overall omission rate.
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Further examination of omitted first doses revealed that although four trusts had very low (1.4 to 3.5%)
overall rates of omission; significant proportions of these omissions (72 to 80%) in three trusts and in one
trust all omissions were first doses. For other trusts their first dose omission rate was more in keeping
with their total omission rate.
6.6 Community Health – all and first dose omissions
Twelve of the 265 doses prescribed for 97 community health patients were omitted – a rate of 4.5%.
Although small numbers of patients were both audited and prescribed antimicrobials the rate of omission
was lower than that for the acute trusts.
9.8 % (26/265) of doses prescribed were first doses and the one (3.8% or 1/26) first dose that was
omitted had nothing recorded in the administration box.
6.7 Mental Health – all and first dose omissions
11.2% (19/170) of doses prescribed in mental health trusts were omitted. 14.7% (25/170) of prescribed
doses were first doses; 20% (5/25) of these were omitted – all were recorded as not being available.
The most common reason for non-administration of all doses was the antimicrobial not being available
(49% - 9/19), this was more than double the rate for acute trusts. In 37% (7/19) of cases the
administration box had been left blank and on one occasion (5%) another reason was recorded. Two
doses (11%) were refused. Refusal of doses was no more common in mental health patients than in
physical health patients in an acute setting.
6.8 Enteral and Parenteral doses – all trusts
All doses prescribed to be administered in mental trusts and 95.6% (250/265) of those prescribed in
community health trusts were enteral. However 56.5% (12085/21390) of the doses prescribed in acute
trusts were intended to be administered parenterally.
In acute trusts 44% (490/1120) of omitted doses were parenteral and 56% (630/1120) were enteral.
Enteral doses were more frequently omitted than parenteral doses and this was statistically significant (p<
0.001).
Table 5 Reasons for omission for enteral and parenteral antimicrobial doses in Acute Trusts
Reason for
Omission
Blank
Other
Not available
Refused
No route
Patient Away
Total
Enteral
Number
%
183
29.0
122
18.6
155
24.6
117
18.6
48
7.6
5
0.8
630
100.0
Parenteral
Number
%
137
28.0
169
34.5
54
11.0
21
4.3
86
17.6
23
4.7
490
100
Acute All
Number
%
320
29
291
26
209
19
138
12
134
12
28
3
1120
100
In acute trusts enteral doses were found to be more frequently “not available“ than parenteral doses (p<
0.001). But “no route” was more frequently cited as a reason for non-administration of parenterals than
enterals (p< 0.001). “Other” was more frequently cited for parenterals (35%) than for enterals (18.6%).
6.9 Results by Care Areas all trusts
Patients in acute and community health trusts were allocated to one of eleven pre-defined care areas by
the pharmacy staff collecting the audit data according to the ward the patient was on. No allowance was
made for outliers. All the community health patients were classified as rehabilitation/intermediate care,
except two care of the elderly patients who received all the doses of antimicrobials prescribed for them.
Mental health trust patients were allocated to one of six care areas that were specific to mental health.
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6.9.1 – Acute Trusts Care Area Demographics
The numbers of patients prescribed antimicrobials in the different care areas varied widely; with quite
small numbers from surgical admissions (68), maternity (70) and intermediate care (71) and over a
thousand in both general surgery (1132) and specialist medicine (1517) – which included infectious
diseases patients. Details are given in Table 6.
Table 6 Demographics of patients and prescribed antimicrobials by acre areas in acute trusts
Care Area
Number of
patients
prescribed
antimicrobials
Number of antimicrobials
prescribed
Number of antimicrobial doses
prescribed
Proportion of
doses that were
parenteral (%)
Admissions surgical
66
91
218
Admissions medical
427
589
1497
Care of the elderly
592
734
1910
Critical Care
358
626
1406
General Medicine
712
1005
2523
General Surgery
1132
1555
4036
Maternity
70
100
266
Paediatrics
548
1058
2223
Intermediate Care
71
84
198
Specialist Medicine1
1517
2300
5680
Specialist Surgery
406
606
1435
Overall data
5899
8748
21390
Note 1 covers eg cardiology, gastro, infectious diseases, respiratory patients
62.6
55.7
39.1
89.6
50.0
64.8
36.0
70.9
16.7
46.3
55.6
56.5
Intermediate care had the smallest proportion of parenteral doses prescribed (16.7%); followed by
maternity at 36%. Critical Care at 89.6% had the highest proportion of parenteral doses prescribed.
6.9.2 Acute Trust Omissions by Care Areas
Information on antimicrobial doses prescribed and omitted are described in Table 7. The table is
ranked with highest omission rates at the top.
The ranking for omissions of first doses remained the same as all doses except for surgical admissions
which moved into second place ahead of care of the elderly. Both intermediate care and surgical
admissions had relatively small numbers of patients prescribed antimicrobials but high omission rates.
In contrast maternity the other care area with small numbers of patients prescribed antimicrobials had
low omission rates of both first and all doses.
Both critical care and paediatrics had large numbers of antimicrobial doses prescribed but low rates of
omission.
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Table 7 Acute Trust numbers of antimicrobial doses and first doses prescribed and omitted by
care areas
Care Area
Intermediate Care
Care of Elderly
Admissions Surgery
General Surgery
Specialist Medicine
General Medicine
Specialist Surgery
Admissions Medicine
Critical Care
Maternity
Paediatrics
Overall data
Number of
doses
prescribed
Number of
doses
omitted
198
1910
218
4036
5860
2523
1435
1497
1406
266
2223
21390
% of all
doses
omitted
17
152
14
242
332
134
71
62
36
7
53
1120
Number of
first doses
prescribed
8.6
8.0
6.4
6.0
5.8
5.3
4.9
4.1
2.6
2.6
2.4
5.2
Number of
first doses
omitted
29
229
38
707
745
288
193
387
198
49
398
3261
8
34
8
76
99
21
13
29
12
1
12
313
% first
doses
omitted
27.6
14.8
21.1
10.7
13.3
7.3
6.7
7.5
6.1
2.0
3.0
9.6
6.9.3 Acute Trust Care Areas Reasons for Omission
Table 8 Acute Trusts Reasons for omission by care area as percentages of all doses omitted in
the care area
Care Area
Admissions medical
Admissions surgical
Care of the elderly
Critical Care
General Medicine
General Surgery
Intermediate Care
Maternity
Paediatrics
Specialist Medicine
Specialist Surgery
Overall
Away
Blank
Refused
No route
0
0
0
11
0
2
0
0
0
5
4
3
32
21
33
14
25
21
29
57
30
32
39
29
26
0
17
3
14
12
12
0
6
11
7
12
8
14
10
11
13
14
6
0
11
14
4
12
Not
available
8
50
24
22
14
21
35
14
6
18
15
19
Other
Total
26
14
16
39
34
31
18
29
47
20
30
26
100
100
100
100
100
100
100
100
100
100
100
100
Patient’s being “away” from the ward was the least frequently reported reason for admission in all care
areas except critical care where patient “refusal” was the least frequently reported (would correlate
with most critical care patients being sedated). “Refusal” was reported for a quarter of medical
admissions omissions.
“No route” available appeared not to be more of an issue in any one care area compared to another.
Leaving the administration box “blank” was the most frequent reason for omission for five of the care
areas (admissions medical, care of the elderly, maternity, specialist medicine and specialist surgery).
But was less of an issue for critical care areas.
For four care areas “other” was the most frequently reported reason for omission and for two areas
intermediate care and surgical admissions “not available” was the most frequently reported reason with
admissions surgical areas reporting 50% of doses omitted for this reason.
6.9.4 Acute Trust “Stat” dose prescribing
Single doses to be administered eg as part of surgical prophylaxis are often prescribed as “stat” doses;
trusts may have a specific section of the drug chart to accommodate this. First doses of a course of
treatment can also be prescribed as “stat” doses and indeed are advocated in some trusts. A single
dose for treatment or prophylaxis was also considered as a first dose for this audit.
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





3261 first doses prescribed
9.5% (313/3261) first doses omitted
21.3 % (695/3261) of first doses were prescribed as stat doses
5.2% (36/695) of stat doses were omitted
2566 first doses were prescribed as regular medication
10.9% (279/2566) of first doses prescribed on the regular side of drug chart were omitted.
Table 9 Acute trusts - Administration of first doses prescribed as “stat” or as regular
medication
Prescribed as “stat”
695 (95.1%)
36 (5.2%)
Administered
Not administered
Prescribed as regular medication
2566 (89.1%)
279 (10.9%) p< 0.001
The first dose of a course of antimicrobials were omitted twice as frequently when prescribed on the
regular side of the drug chart compared to the “stat” section of a drug chart. This was a statistically
significant difference. (p<0.001)
A detailed table of omissions of first doses, “stat” doses and first doses prescribed as stat doses by
acute trust care areas is in Appendix C.
6.10 Omissions by care area for Community and Mental Health patients
All but two of the community health patients were from the rehabilitation /intermediate care area and all
twelve omissions related to this care area. The two care of the elderly patients received all of the
prescribed doses of antimicrobials. 4.5% (12/265) of all antimicrobials doses were omitted and 3.8%
(1/26) of first doses were omitted.
For mental health patients no data was recorded for Child and Adolescent nor for Eating Disorder
patients. No doses were omitted in Learning Difficulties and only two (and no first doses) in Secure and
Forensic Health patients. Details of the omissions for the four mental health care areas where omissions
occurred are described in Table 10. The table is ranked with the highest omission rate at the top.
Table 10 Mental Health All and First dose omissions of antimicrobials by care areas
Care Area
Working Age
Mental Health
Older Peoples
Mental Health
Secure &
Forensic Health
Learning
Disabilities
Overall
Number of
doses
prescribed
45
Number of
doses
omitted
9
% doses
omitted
20.0
Number of
first doses
prescribed
7
Number of
first doses
omitted
3
81
% first
doses
omitted
42.9
8
9.9
14
2
14.3
38
2
5.3
3
0
0.0
6
0
0.0
1
0
0.0
170
19
11.2
25
5
20.0
6.11 Results for delayed last doses
The last dose prescribed to be given was assessed by the data collectors as to whether it had been given
or if was overdue in which case it was considered delayed. The delay at the time of the audit was
measured in hours (underestimating the duration of the delay but identifying the number of doses that had
been delayed)
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6.11.1 Delays - Acute Trusts






8748 last doses were prescribed
6.4% (562/8748) were recorded as delayed
28% (157/562) of delayed doses were delayed by up to 1 hour at the time of the audit.
54% (302/562) of delayed doses were delayed by up to 2 hours at the time of the audit
80% (454/562) of delayed doses were delayed by up to 4 hours at the time of the audit
7.9% (465/5899) of patients (1 in 13) experienced a delayed dose
Figure 2 Acute Trusts delayed antimicrobial doses by length of delay at time of audit
A first dose prescribed to be given could also be the last dose due to be given during the audit period.
42% (236/562) of the delayed doses were first doses. 7.2% (236/3261) of first doses were delayed.
First dose delays followed a similar pattern of length of delay to that seen with all dose delays.
6.11.2 Acute Trust Delayed Parenteral and Enteral antimicrobial doses
There was no statistically significant difference in the frequency of delays between enteral and
parenteral doses.
Table 11 Acute Trusts – delayed parenteral and enteral antimicrobial doses
Number of doses prescribed
Number of doses delayed
% of doses delayed
Parenteral antimicrobials
doses
12107
311
2.56%
Enteral antimicrobial
doses
9283
251
2.7%
6.11.3 Acute Trust Delays by Care Area
All care areas experienced delayed last doses, maternity and paediatrics had higher proportions of
delays compared to other care areas; although both of these care areas had low omission rates
compared to other care areas. Table 12 ranks the care areas by percentage of last doses delayed.
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Table 12 Acute Trusts – delayed doses by care areas
Care Area
Paediatrics
Maternity
Care of the elderly
Intermediate Care
Admission surgical
General Medicine
Specialist Medicine
General Surgery
Admission medical
Specialist Surgery
Critical Care
Overall data
Number of last
doses
prescribed
1058
100
734
84
91
1005
2300
1555
589
606
626
8748
Number of
delayed last
doses
125
11
68
6
6
57
125
84
29
26
25
562
% of last
doses
delayed
% patients who had a
delayed dose
11.8
11.0
9.3
7.1
6.6
5.7
5.4
5.4
4.9
4.3
4.0
6.4
22.8
15.7
11.5
8.5
9.1
8.0
8.2
7.4
6.8
6.4
7.0
9.5
6.11.4 Delayed Doses Community and Mental Health Patients
Only one Community Health dose was delayed; which was by at least four hours and this was a
rehabilitation/intermediate care patient. There were two Mental Health doses delayed by at least two
hours; these were in Older People’s Mental Health.
6.12 Electronic prescribing sites compared to traditional prescribing
As electronic prescribing is thought to bring benefits to patients a sub-analysis of electronic prescribing
versus traditional prescribing sites was performed to see if electronic prescribing reduced the number of
omissions and delay.
The omission rate for both types of prescribing was exactly the same (5.2%)
However the omission rate for electronic prescribing sites was lower for first doses (8.7%) compared to
traditional prescribing sites (9.7%) however this difference was not statistically significant.
A greater proportion of first doses are prescribed as “stat” in electronic prescribing sites compared to
traditional prescribing (32.1% v 20.4%). And changing the route eg from parenteral to oral creates a new
prescription in electronic prescribing systems whilst for many trusts multiple routes of administration would
count as one prescription when prescribed on paper.
Table 13 Acute Trusts – Antimicrobial dose omission by electronic and traditional prescribing
sites
Electronic Prescribing sites
Traditional Prescribing sites
All doses
% of antimicrobial doses
administered
1805/1904 (94.8%)
18465/19486 (94.8%)
20270/21390 (94.8%)
% of antimicrobial doses
omitted
99/1904
(5.2%)
1021/19486 (5.2%)
1120/21390 (5.2%)
The reasons for omission were similar between electronic prescribing and traditional prescribing sites; see
Table 14. Despite having an electronic prescribing system 19% of administration records were left blank.
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Table 14 Acute Trusts – Comparison of reasons for omission for electronic and traditional
prescribing sites
Reasons for Omission
Blank
Other
Not available
Refused
No route
Patient Away
Total
Omitted antimicrobial doses
Electronic Prescribing Sites
Traditional Prescribing sites
Number
%
Number
%
19
19.2
301
29.5
34
34.3
257
25.2
15
15.2
194
19.0
13
13.1
125
12.2
17
17.2
117
11.5
1
1.0
27
2.6
99
100.0
1021
100.0
A larger proportion of doses were reported as delays by trusts using electronic prescribing (16% 133/831)
than traditional prescribing 5.4% (429/7919). This difference was statistically significant (p< 0.001). 1 in 3.6
patients from electronic prescribing sites experienced a delayed dose whilst for traditional prescribing
sites the number reported was 1 in 12.
Table 15 Acute Trusts – comparison of delayed last doses for electronic and traditional
prescribing sites
Last doses prescribed
Delayed Last doses
Number of patients prescribed
antimicrobials
No of patients with a delayed
dose
Electronic Prescribing Sites
Number
%
831
133
16%
1224
339
27.7%
Traditional Prescribing Sites
Number
%
7919
429
5.4%
5419
428
7.9%
7. Discussion
Was it appropriate to focus on antimicrobials rather than all medicines?
The NPSA recommended trusts should have a list of medicines where delays or omissions were
considered to be critical; they also advised that antimicrobials (along with anti-coagulants, insulin,
resuscitation medicines and medicines for Parkinson’s Disease) were included on the list. Antimicrobials
are used by all care areas in all types of trust which allowed a wide range of organisations to participate.
Antimicrobials are frequently prescribed agents and all health care staff should have an awareness of the
importance of administering antimicrobials; suggesting that performance with antimicrobials is likely to
reflect similar performance with other medicines. Focusing on antimicrobials made the data set more
manageable.
What were the most frequently reported reasons for omission in acute trusts?
Leaving the administration box blank was the most frequently reported reason for omission (29% of cases
of missed doses).
Where possible Pharmacy Staff followed up whether the nurse had given the dose but had forgotten to
sign the chart. For 20.9% of the blank administration boxes it was possible to confirm with the nurse this
was the case. The data may have been skewed by the way the information was obtained and the
pharmacy staff were not always able to complete the task. However this was such a large proportion of
the missed doses that work needs to be undertaken locally with nursing staff to improve record keeping
(Standard 8 point 2.10 of the Nursing and Midwifery Council’s Standards for Medicines Management2
states ‘……you must make a clear accurate and immediate record of all medicines administered,
intentionally withheld or refused by the patient ensuring the signature is clear and legible ….. In addition
….. where medication is not given the reason for not doing so must be recorded…..). Raising the
awareness of the importance of patient’s receiving their medication on time is also key.
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The second most frequently reported reason for omission was “Other” at 26% – these were omissions
where a recorded reason for omission had been made but it was not covered by one of the remaining five
reasons. “Other” could include waiting for a level; withheld on prescriber’s instructions, unable to read the
prescription etc. Some of these omissions could be considered intentional and therefore justified – but
more local investigation is required and solutions implemented to reduce the risk to patients.
19% of omitted doses were recorded as “Not available”. Where this was the case auditors searched for
the dose on the ward to see if it had been available at the time the dose was due. In 30% of cases the
dose was assessed as being available for administration. This figure may be an under-estimate because
the search for all “non-available” doses may not have been completed. Further analysis of the “not
availables” was undertaken to see if the method of supply affected the omission rates; and these results
are discussed later.
Overall 12% of omitted doses were due to patient’s refusing doses. The proportion of doses missed for
this reason was higher in care of the elderly and in medical admissions. Clear explanations to patients
about new treatments started may help adherence.
The same percentage of omitted doses was due to the route of administration not being available to use,
this would include no intravenous access or no nasogastric (ng) tube in place. Prescribers need to be
aware of routes available at the time of prescribing and where necessary plan ahead if a route this likely
to become unavailable eg poor veneous access or confused patient’s removing ng tubes. Nursing staff
must liaise promptly and medical staff must respond promptly to such situations.
Patients being Away from the ward provided the smallest percentage (3%) of omitted doses. However
Trusts must have clear processes for “catching up” with doses omitted or delayed.
Are first doses omitted more than other doses?
First doses were found to be omitted more often than other doses. In acute trusts patients were found to
miss first doses twice as often as other doses and this was the case across all care areas. This was an
important finding because first doses of antimicrobial courses may be critical (eg in sepsis). This was a
particular issue for surgical admissions where timely administration of antimicrobial prophylaxis and
therapy is vital.
A smaller proportion of first doses were audited in community health and mental health settings it is
therefore more difficult to draw conclusions.
The audit showed acute trust patients were twice as likely to miss a first dose because it was not available
(33%) compared to all doses (19%) and this was a statistically significant finding.
Should the first dose of a course of treatment be prescribed as a stat dose?
The audit suggests prescribing first doses as stat does reduce the omission of doses. First doses were
omitted twice as frequently when prescribed on the regular side of the drug chart (10.9% - 279/2566)
compared to prescribing as a stat dose (5.2% - 36/695).
The omission rate of first doses in Electronic Prescribing sites was lower than traditional prescribing sites
(8.7% v 9.7%) but was not statistically significantly different. However a greater proportion of first doses
are prescribed as stat in electronic prescribing sites (32.4% v 20.4%) and these tend to be omitted less
frequently than first doses prescribed as part of a regular prescription.
Some trusts have a policy that first doses of courses of treatment should be prescribed as a stat dose; as
the omission rate was lower than for first doses prescribed on the regular part of the drug chart the audit
results suggest all trusts should adopt such a policy. A review of local policies where they do exist is also
recommended as anecdotally it would appear that although such a policy may exist it is not always
adhered to.
Are doses omitted more often from some care areas than others?
Omission rates varied in care areas from 2.4% in paediatrics to 8.6% in intermediate care. Omission
frequencies were highest in intermediate care, care of the elderly and surgical admission care areas in
acute trusts (although the small numbers of intermediate care patients make the findings in this care area
less reliable). Local actions on omitted doses should be prioritised to the areas that have particular issues
for individual trusts.
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A smaller proportion of community health care area patients (14.7%) were prescribed antimicrobials but
doses were missed less frequently (4.5%) compared to acute care settings (5.2%). There is however a
problem to be addressed.
An even smaller proportion of patients in mental health settings (4.3%) were prescribed antimicrobials but
these patients missed doses more frequently than those in acute care settings (11.2% of doses omitted
compared to 5.2%) and more often because the dose was not available (49% v 19%). Mental Health
Trusts are encouraged to review supply processes locally.
Does being on a stock list improve the likelihood of a dose being given?
Patients were found to miss twice as many doses if the antimicrobial was supplied against an individual
prescription compared to those available in the clinical area as stock. This was statistically significant.
Locally trusts must review supply processes – including access to anti-microbials out of hours. And stock
lists must be reviewed regularly.
Traditional methods of controlling access to antimicrobials (ie requesting an individual prescription to
dispense against) appear to lead to more missed doses.
Concerns about resistance developing could be reduced by adopting the Department of Health’s
3
approach of Start Smart then Focus where prompt effective anti-microbial treatment is initiated against
local guidelines within an hour of diagnosis then a Focus is made by reviewing by 48 hours to Stop,
Switch, Change Continue or OPAT (outpatient parenteral antibiotic therapy)
Are restricted antimicrobials missed more often than freely available agents?
No there was no statistically significant difference between omissions of restricted antimicrobials and
those freely available; unlike those that are not stocked onwards.
Were delayed doses less of a problem than omitted doses?
Unfortunately not – there were fewer last doses prescribed (8923) however a greater proportion of these
were delayed (6.3% - 565/8923) compared to doses being omitted (5.3% - 1151/21825).
The audit identified the number of doses that were delayed but the length of the delays was an underestimate as the duration of the delay was measured at the time of data collection rather than up to when
the dose was eventually given (a number of these delays would go on to become omissions if the delay
lasted until the next prescribed dose was due).
The audit did not identify the number of patients whose dose was delayed because they were away from
the ward – so it was not possible to contrast those patients missing a dose and those catching up with
dose when they returned to the ward later
What can be done to reduce delays?
Similar actions as those needed to reduce omissions will help reduce the number of delays; including
raising awareness to ensure doses are given on time; particularly for first doses. A higher proportion of
first doses were delayed (7.2% - 236/3261) compared to all doses (6.3% - 565/8923). Providing
guidance on what do to about doses that get out of synch with their prescribed times may be helpful.
Was patients being “away” from the ward an issue for delays and omissions?
Patients being away from the ward accounted for a relatively small percentage of omissions (3%).
Reasons for delayed doses were not recorded but could include being away from the ward. The delayed
dose data was not sensitive enough to identify if patients being away from the ward caught up with doses
later and therefore did not turn into an omission.
Are parenteral doses delayed or omitted more often than enteral ones?
Although the overall data showed there was no difference in delays of parenteral and enteral doses; a
closer look at local data would be helpful in trusts where the practice is to give enteral medication first and
then give the parenteral doses. Enteral doses were more frequently omitted than parenteral ones this
could be because more importance is given to parenteral than enteral doses because the route of
administration implies the patient is sicker.
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Does electronic prescribing reduce the frequency of omissions and/or delays?
No difference was found in the omission rates for electronic prescribing and traditional prescribing sites.
There were slightly fewer first dose delays in electronic prescribing sites. Electronic prescribing sites like
traditional prescribing sites had a significant proportion of omissions where the administration box was left
blank.
There was however a higher proportion of delays reported for electronic prescribing sites, this data would
have been easier and more accurate to collect and may be a more true representation of delays.
Was the methodology robust?
Point prevalence data collection is a well recognised methodology and is already in place in many trusts
for collecting antimicrobial prescribing data. The data collection forms and spread sheets can be used per
se or adapted for use by organisations to repeat delayed and omitted dose audits; there are examples of
this happening.
What were the limitations of the audit?
A large number of people collected the data from clinical areas and then a smaller number of people
entered data onto the trust’s spread sheets. It was assumed data had been collected and entered as
intended. Despite detailed guidance being given; there could have been local interpretation and there was
a need to cleanse the data submitted and ensure all the relevant boxes had an entry.
The number of omissions and delays could be an under-estimate of the true picture as data was not
collected on Mondays to mitigate against different supply mechanisms at the weekend.
The study design allowed for an accurate record of the number of doses delayed to be measured but it
was not possible to measure the exact duration of the delays as the data was collected at a specific point
in time. Different methodology (such as an observational study) would need to be used to measure the
delays accurately. However, it is generally recommended that first doses should be administered within
an hour of the prescribed time and other doses within two 2 hours. This audit was sensitive enough to
show that there is an issue with delayed doses.
Trusts decided whether to audit all occupied beds or to target care areas; this may have skewed data
particularly for those care areas with small numbers.
The audit did not distinguish between doses prescribed for treatment or for prophylaxis.
For electronic prescribing sites the number of “courses” of treatment given may appear high as stat doses
and change of route prescribing is recorded as a separate prescription.
8. Summary
Omitted and Delayed doses were found to be affecting 13.2% and 7.7% of the patients audited who had
been prescribed antimicrobial agents during a 24 hour period in December 2010. In acute trusts 5.2% of
prescribed doses were omitted; the commonest reason was because nothing was documented in the
administration box (29%); non-availability of the dose was recorded in 19% of cases; no route and refusal
were both 12% and away from the ward just 3%. In 26% of cases the omission was due to a reason not
covered by the other categories.
First doses of a course; first doses not prescribed as stat and antimicrobials not stocked on the ward were
twice as likely to be missed. 19% of doses reported as not available were found on the ward and would
have been available to administer. On follow up at least 29% of doses not signed as being administered
had been given.
There were differences in omission rates for different care areas in acute trusts; care of the elderly
patients had a high omission rate and critical care and paediatrics a low omission rate.
Electronic prescribing sites had the same omission rate as traditional prescribing sites.
Mental Health and Community Health patients were prescribed fewer antimicrobials compared to acute
trusts. 16.7% of mental health patients missed at least one dose more often through non-availability than
in acute trusts.
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The issues influencing delayed and omitted antimicrobial doses are multi-factorial, complex and require
multi-disciplinary solutions.
9. References
1. National Patient Safety Agency Rapid Response Report NPSA/2010/RRR009: Reducing harm from
omitted and delayed medicines in hospital. February 2010.
2. Nursing and Midwifery Council Standards for Medicines Management. NMC 2007
3. Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated
Infection (ARHAI) - Antimicrobial Stewardship: “Start Smart - then Focus”. Department of Health
London 2011.
10. Acknowledgements
Many thanks are offered to
Pharmacy Staff who collected the data
Local audit co-ordinators for ensuring consistency of data collection and data entry
Karen Colls for her Excel expertise
Christine Masterson for excellent administrative support
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Appendix A. Participating Trusts
Ashford & St Peter’s Hospitals NHS Trust
Basildon & Thurrock University Hospitals NHS Foundation Trust
Basingstoke and North Hampshire NHS Foundation Trust
Bedford Hospital NHS Trust
Berkshire Healthcare NHS Foundation Trust
Buckinghamshire Hospitals NHS Trust
Central London Community Healthcare
Chelsea and Westminster Hospital NHS Trust
Colchester Hospital University NHS Foundation Trust
Croydon University Hospital Trust
Dartford and Gravesham NHS Trust – Admissions
Ealing Hospital NHS Trust
East & North Hertfordshire NHS Trust
East Kent Hospitals University NHS Foundation Trust
East London NHS Foundation Trust
East Sussex Community Health Services
East Sussex NHS Trust
Frimley Park Hospital NHS Foundation Trust
Great Ormond Street Hospital for Children
Heatherwood and Wexham Park Hospitals NHS Foundation Trust
Hillingdon Hospital NHS Trust
Hinchingbrooke NHS Trust
Imperial College Healthcare NHS Trust
James Paget University Hospitals NHS Foundation Trust
Kingston Hospital NHS Trust
Luton and Dunstable Hospital NHS Foundation Trust
Medway NHS Foundation Trust
Mid Essex Hospital Services NHS Trust
Milton Keynes NHS Foundation Trust
NHS Isle of Wight
Norfolk & Norwich NHS Trust
Norfolk Community Health and Care NHS Trust
Nuffield Orthopaedic Centre NHS Trust
Oxford Radcliffe Hospitals NHS Trust
Oxfordshire and Buckinghamshire Mental Health Partnership NHS Trust
Papworth Hospital NHS Foundation Trust
Princess Alexandra Hospital NHS Trust
Queen Victoria NHS Foundation Trust
Royal Brompton and Harefield NHS Foundation Trust
Royal Marsden NHS Foundation Trust
Royal Surrey County Hospital NHS Trust
South Essex Partnership University NHS Foundation Trust
Southend University Hospital NHS Foundation Trust
St Georges Healthcare NHS Trust
Suffolk Mental Health Partnership NHS Trust
Surrey and Sussex Healthcare NHS Trust
Sussex Community NHS Trust
Sussex Partnership NHS Foundation trust
University College London Hospitals NHS Foundation Trust
West Hertfordshire Hospitals NHS Trust
West Middlesex University Hospital NHS Trust
Western Sussex Hospitals Trust
Whipps Cross University Hospital NHS Trust
Winchester & Eastleigh Hospitals NHS Trust
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Appendix B
Guidance Notes on How to complete Data Collection Form
Omitted and Delayed Antimicrobials Collaborative Audit
Please read before starting your data collection
On the day of the audit – review all the antimicrobial doses prescribed to be given in the preceding 24
hours. Complete one line for each patient with a current antimicrobial prescription (definitions below),
even if there are no omissions or delays. For one omitted or delayed dose complete all details on that line.
If more than one omitted dose use the line below to record reasons etc – bracket the two lines together.
Where questions are not applicable record a dash
Question
Bed number
Antimicrobial
Route
On Ward Stock List?
Restricted
Rxed doses in 24 hrs
First Dose Info
(Rxed and stat and
omitted)
Number of Omitted
Doses
Reason omitted
Not available – was it
found
Blank – was it given
and nurse forgot to
sign?
Last dose delayed
Delayed dose – how
long
For (hrs)
Guidance to complete
This is just to help you know which patients you have collected data for it won’t be
used in the analysis – you can use another system – ensuring patient confidentiality
Name of the antimicrobial – see below for definition
Record parenteral & enteral routes. Note we are not auditing topical routes or nebs
Answer yes if the antimicrobial is on the ward stock list – it does not mean that it was
actually available on the ward
Answer yes if the antimicrobial is restricted in your organisation eg it requires micro
approval or pharmacy check that it meets indication before it is issued
Count the doses prescribed to be given over the preceding 24 hours.
Covers first doses of courses prescribed to be administered during the 24 hour audit
period.
Answer yes if the first dose is included in the audit; No if it was given prior to the
audit.
Then answer yes if it was prescribed as a stat dose with the rest of course on regular
section of the drug chart or (N) if entire course is prescribed on the regular section
of the drug chart
and finally if this dose was omitted – answer yes and continue with the omission
reasons on the same line of the data collection form. If the answer is no enter the
omission details of any further omitted doses on the rest of the line.
Record the number of doses of the antimicrobial that been omitted during the 24
hour audit period – see below for definition. The total includes any omitted first
doses. But does not include any delayed doses. If the last dose prescribed to be
administered during the 24 hour audit period has not been - given record this as a
delay at the end of the row.
Do not use your local omission codes as everywhere has different ones! See below
for full descriptions – shortened codes are on the bottom of the data collection form.
Include “blanks” this is where there is nothing written in the administration box for a
dose; but the next prescribed dose has been given. Where there is a “blank” for the
last dose in the audit to be given record this as a delay.
For those omissions where the antimicrobial was not available on the care area;
attempt to validate if it was actually available. Record yes if the antimicrobial was
found on the ward or was available in an Emergency Drug Cupboard out of hours.
For doses where there is nothing recorded in the administration box can you confirm
if the dose was actually given but nurse but they forgot to sign, if so record Yes.
Where unable to validate record N. If this relates to the last dose to be given in the
audit record as a delay.
Record yes if the administration box for the last dose prescribed to be given during
the audit is blank – signifying the dose has been delayed.
Where the last dose prescribed for administration during the audit has not been
given record the number of hours (to the nearest whole number) between the
prescribed time and the data collection time. Not expecting you to be able to identify
delays for doses administered earlier as times of administration are rarely recorded.
Don’t forget to complete your name (in case of queries, ward name and date and time of audit.
Record the number of patients on the ward, the number with a current antimicrobial prescription and
the total number of antimicrobial courses currently prescribed .
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Guidance Notes on How to complete Data Collection Form
Omitted and Delayed Antimicrobials Collaborative Audit
Definitions for the purposes of the collaborative audit
Antimicrobial
Audit
24 hour Audit period
Blank
Course
Current Prescription
Delayed dose
Enteral
First dose
Omitted Dose/Omission
Parenteral
Stat/Stat Dose
Any agent that appears in Chapter 5 of the BNF that is given
systemically ie topical applications and nebules are excluded but
all parenteral and enteral routes are included
The data for the audit can be carried out on any day (reviewing
prescriptions for the preceding 24 hours) between Tues 23 rd and
Fri 26th Nov or Tues 30th Nov and Fri 3rd Dec.
The 24 hours preceding the start of the data collection ie if data
collection starts at 4pm on Wed 24 th, review prescriptions back to
4pm on Tues 23rd.
The administration box has been left entirely blank
A course of treatment eg 5 days of oral amoxicillin
Antimicrobial prescription that is valid for administration of doses
during the 24 hour audit period
Doses not administered at the time specified by the prescriber.
There can be different degrees of delay.
Antimicrobials given for systemic infections by the oral,
nasogastric, PEG or other “tubes” Exclude Nystatin liquid.
The first dose to be given as part of the course of treatment.
Doses not administered by the time the next dose is due to be
given.
Antimicrobials given by injectable routes eg intravenous,
intramuscular
Doses prescribed as one-offs usually on a specific section of the
drug chart – sometimes the first dose a course is prescribed as a
stat dose and the rest of the course on the regular section of the
drug chart
Omission Code Definitions
Code
Away
Refused
No route
Not avail
Other with reason
Blank
Covers
Patient Away from the ward
Patient refuses
The prescribed route is not available for a variety of reasons
Eg Patient Nil by mouth, vomiting
Not cannulated
Cannula tissued
Fasting
Unable to take
Antimicrobial not available on the ward to be given at that time
Things not covered by the above but there is a documented reason to eg
with-held on prescribers instructions, awaiting a result back
No signature in the administration box
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Appendix B
Data Collection Form
Omitted and Delayed Antimicrobials Collaborative Audit - Individual Antimicrobial Data Collection Form A
Please Read accompanying guidance before completing
Name of auditor
Ward
No of pts seen
Bed
Antimicrobial
Date of audit
No of pts current antimicrobial Rx
Route
On
ward
Stock
list
(Y/N)
Restrict
- ed?
(Y/N)
Rx’d
doses
in 24 hr
Total no of anti-microbial courses prescribed
First dose info
Rxed
Rxed
stat
(Y/N)
Omitt
ed
(Y/N)
Y
N
Eg1
Tazocin
IV
N
Y
3
Y
N
Eg 2
Gent
IV
Y
N
1
Y
Y
Number omitted
doses (If more
than 1 complete
more lines –
bracket together )
2}
}
-
A collaborative audit of omitted and delayed anti-microbial doses – v 1.1 May2015 (JH/JN)
Reason
omitted?
See
below
‘Not available’
was it found?
(Y/N)
Not avail
Blank
-
Y
-
‘Blank’
Was it given &
nurse forgot to
sign
(Y/N)
Last dose
delayed
(Y/N)
N
-
N
Y
Last dose
delayed
For hrs
(Nearest
whole no)
4
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Medicines Use and Safety
Appendix C
First dose prescribed as “Stat” or on the regular side of the drug chart and omissions by care area
Care Area
Admission surgical
Admission medical
Care of the elderly
Critical Care
General Medicine
General Surgery
Maternity
Paediatrics
Intermediate Care
Specialist Medicine
Specialist Surgery
Overall data
Number of
first doses
prescribed
38
387
229
198
288
707
49
398
29
745
193
3261
Number of
Stat doses
prescribed
6
81
39
50
57
206
7
89
1
126
35
695
% of first
doses
prescribed as
stat
15.8
20.9
17.0
24.7
19.8
29.1
14.3
22.4
3.4
16.8
18.1
21.3
Number of
stat doses
omitted
% of first
doses
prescribed as
stat omitted
Number of
first doses
prescribed on
regular side
% of first
doses
prescribed on
regular side
No of first
doses
prescribed on
regular side
omitted
% of first
doses
prescribed on
regular side
omitted
0
7.4
2.6
0
5.3
6.3
0
0
0
10.4
0
5.2
32
306
190
149
231
501
42
309
28
620
158
2566
84.2
79.1
83.0
75.3
80.2
71.9
85.7
77.6
96.6
83.2
81.9
88.7
8
23
33
12
18
63
1
12
8
86
13
277
25.0
7.5
17.4
8.1
7.8
12.6
2.4
3.9
28.6
13.9
8.2
10.8
0
6
1
0
3
13
0
0
0
13
0
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