NPC Archive Item: Reducing harm from omitted and delayed medicines in hospital

30 April 2010

Introduction
In February 2010 the National Patient Safety Agency’s (NPSA’s) Rapid Response Report ‘Reducing harm from omitted and delayed medicines in hospital’¹ was published to alert health professionals of the dangers caused by delays or omissions in patient treatment. Omissions or delays in patient treatment can happen as a result of errors during the prescribing, dispensing, supply or administration of the medicines in hospitals.¹

Action
A nominated Executive Director from all organisations in the NHS and independent sector who admit patients for in-patient treatment is required to:

1. Identify a list of critical medicines where timeliness of administration is crucial (to include anti-infectives, anticoagulants, insulin, resuscitation medicines and medicines for Parkinson’s disease, and other medicines identified locally);
2. Ensure medicines 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;
3. Review and, where necessary, make changes to systems for the supply of urgent medicines within and out-of-hours to minimise risks;
4. Review incident reports regularly and carry out an annual audit of omitted and delayed critical medicines. Ensure that system improvements to reduce harm from omitted and delayed medicines are made. This information should be included in the organisation’s annual medication safety report; and
5. Make all staff aware that omission or delay of critical medicines, for inpatients or on discharge from hospital, are patient safety incidents and should be reported.¹

Background
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.¹

A review of medication incidents in 2007 by the NPSA² revealed that omitted and delayed medicines was the second largest cause of medication incidents reported to the National Reporting and Learning System (NRLS).

What does this mean to medicines management?
The introduction of e-prescribing and medicines administration systems introduces new risks to the administration of medicines and potentially magnifies existing ones.¹ These need to be taken into account within those NHS organisations that have implemented these systems.

Medicines management procedures should include guidance on the timeliness of medicines administration. Individual NHS organisations should decide what this guidance should be to meet the needs of their patients.¹

How does this relate to other publications or evidence?
Supporting information that accompanies the report suggests that:

• Medicines management procedures should include guidance on a range of topics including medicines reconciliation and the use of patient’s own medicines. Information on both of these topics can be found on the NPC website – Service efficiency and reducing waste, and Patient safety and risk
• Self administration of medicines should be considered for appropriate patients – see the NPC section –  for information
• Organisations avail themselves of the NHS Institute for Innovation & Improvement’s initiative ‘The Productive Ward: releasing time to care’, which includes a module on ways to streamline medicines rounds and minimise interruptions to performing them.

References

1. National Patient Safety Agency (2010). Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital.
2. National Patient Safety Agency (2009). Safety in Doses. Improving the use of medicines in the NHS.

All websites last accessed 15^th April 2010

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