Evaluation of Missing Medication Doses in Hospital Drug Distribution Processes

Signature Grand, Davie, Florida, USA

Objective. To investigate the causes of missing medication doses (MMD) in a hospital drug distribution system and to generate ways to minimize these problems. Background. MMD are considered to be medication errors. Omission of a dose or delay of medication administration may contribute to negative patient outcome. Information to determine the root cause of MMD is still limited. Methods. This is a prospective, observational, single center study conducted over a month. Labels for MMD were generated daily if necessary from each nursing unit. All labels for schedule medications were reprinted and verified daily. Exclusion criteria were “On Demand” and “PRN’ medications. Labels were evaluated for causes of MMD and comparisons of MMD between nursing units. Results. A total of 352 MMD labels were evaluated. The two major reasons for MMD were patient transfers from one nursing unit to another (59.9%) and new admissions (14.8%). Analyses revealed 6 North and 6 South had the highest volume of MMD (20.5%) followed by 4 Main (18.5%). Medications which were not floor stock (>74%) accounted for the highest MMD. Conclusion. Transfer from one unit to another accounted for the highest incident of MMD followed by new admissions. Majority of the MMD included medications that were not floor stock. It is recommended that pharmacy should expand the automation on the floor to include drugs which are more frequently ordered and to implement a detail check list including transfer of medications during patients transfer from one unit to another.