Medication omission in acutely ill patients and its implications for ICU nurse led outreach services

Abstract

Preventable medication errors in patients hospitalised in general wards are a leading cause of unintended patient harm and have been associated with unplanned admissions to the intensive care unit (ICU). A considerable body of knowledge now exists to assist clinicians identify and correct workplace factors that precipitate medication errors, nonetheless, they continue to feature prominently in reports of adverse events in Australia and internationally. 1 Australian Institute of Health Welfare Hospital performance indicators. Towards national indicators of safety and quality in health care. Cat. no. HSE 75. AIHW, Canberra2009 Google Scholar , 2 Fogarty G. McKeon C. Patient safety during medication administration: The influence of organizational and individual variables on unsafe work practices and medication errors. Ergonomics. 2006; 49: 444-456 Crossref PubMed Scopus (65) Google Scholar , 3 Tam V. Knowles S. Cornish P. Fine N. Marchesana R. Etchells E. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. Can Med Assoc J. 2005; 173: 510-515 Crossref PubMed Scopus (621) Google Scholar , 4 Slee A. Farrar K. Hughes D. Constable S. Medication errors on admission to UK hospitals. BMJ. 2005; 331: 534 Google Scholar Common types of medication errors associated with adverse drug events in hospitalised patients include the wrong dose, wrong medication or a wrong route of administration. 5 Phillips J. Beam S. Brinker A. Holquist C. Honig P. Lee L. Pamer C. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. 2001; 58: 1835-1841 PubMed Google Scholar , 6 McBride-Henry K. Foureur M. Medication administration error: understanding the issues. AJAN. 2006; 23: 33-41 Google Scholar What is less well understood is the prevalence of prescribed medications being omitted, the reasons underlying missed medication doses (MMDs) and how omitted medications are recorded/reported as constituting an adverse event.