A Comprehensive Audit of Omissions of Medication After Acute Medical Admission: Which Medications Are Omitted and Why, and How Are Omissions Changing Over Time?
Introduction: · Omission in giving prescribed medications was one of the most frequent causes of Medical Incidents reported to the National Patient Safety Agency1; which recommends its regular re-audit. · The Francis Report2 recommended frequent checks to ensure inpatients receive what they are prescribed.
· The following were prospectively audited in 2014 for doses prescribed for i) Acute Medical Inpatients in a large teaching hospital (n=5405) and ii) in a Specialist Area – the Acute Stroke Unit (n=2992):
1) The Proportion of prescribed medications omitted
2) The Medication category omitted
3) The Reasons for which medications were prescribed but never given; using the 10 categories from the Prescription Kardex chart.
· Two comparisons were made: a) Medical Inpatients vs a medical specialty [Stroke] b) 2014 versus 2011 for Stroke Inpatients. In the interim, ensuring critical medications are given was emphasised.
Results: · 10.0% of medication doses prescribed for Acute Medicine Inpatients (2014) were never given.
· For the specialist unit inpatients (Acute Stroke) by comparison: 18.3%(2011) and 15.3%(2014) of medications were prescribed but never given to Acute Stroke Inpatients. This represented a 16% reduction in medications prescribed but never given to Acute Stroke Inpatients 2014 versus 2011.
· Ten most frequent Reasons for omission for Acute Medical Inpatients in 2014 were ranked, led by ‘patient refused’(43%) and ‘medicine not available’(18%). · The top 10 Categories of medication most frequently omitted in Acute Medicine and the specialist area were ranked. In the Acute Stroke Unit in 2011 these were important medications: antihypertensives(15%), analgesia(12%), versus less critical medications – laxatives(18%), vitamins(18%), by 2014.
Conclusions: · This study shows that prescribed medications are frequently omitted after for Acute Medical Inpatients (1 in10) and even more are omitted after Acute Stroke (1 in 7). The latter may be explained by different causes for omissions after stroke, especially lack of route for administration.
· The ten most common Reasons for omissions in medications reveal that many omissions were likely to have been unnecessary and may be avoided by simple measures by healthcare professionals.
· There were improvements: omitted medications after stroke decreased between 2011 and 2014 and medications most frequently omitted changed from important medicines (2011) to less critical medicines (2014). · Reasons for prescribed medication doses never being given and more importantly, practical remedies to improve omissions, will be discussed.
References : 1 National Patient Safety Agency (2010). Rapid Response Report. Reducing Harm from Omitted and Delayed Medicines in Hospital. NPSA/2010/ RRR009. 2 Francis R (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office.