For IMMEDIATE ACTION by all organisations in the NHS and independent sector who admit patients for in-patient treatment.

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.

Actions:

The deadline for ACTION COMPLETE is no later than 24 February 2011. 

An executive director, nominated by the chief executive, working with the chief pharmacist and relevant medical/nursing staff should:

Action 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;

Action 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;

Action 3: review and, where necessary, make changes to systems for the supply of critical medicines within and out-of-hours to minimise risks;

Action 4: review incident reports regularly and carry out an annual audit of omitted and delayed critical medicines.  Ensure system improvements to reduce harms from omitted and delayed medicines are made. This information should be included in the organisations annual medication safety report;

Action 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.

Further information

Supporting information including evidence of harm and compliance checklists is available at www.nrls.npsa.nhs.uk/alerts. Further queries should be directed to the NPSA medication safety team at rrr@npsa.nhs.uk; telephone 020 7927 9890.