Non-Therapeutic Medication Omissions: Incidence and Predictors at an Australian Hospital

Article (PDF Available)inJournal of Pharmacy Practice and Research 41(3) · September 2011with52 Reads
DOI: 10.1002/j.2055-2335.2011.tb00859.x
Abstract
Background The inconsistent definition of non-therapeutic medication omissions, under-reporting, and a poor understanding of their associated factors hamper efforts to improve medication administration practices.AimTo examine the incidence of non-therapeutic medication omissions among acutely ill medical and surgical adult patients; and to identify the patient-, drug- and system-related predictors of these omissions.MethodA medication chart audit of 288 acutely ill adult medical and surgical patients admitted to 4 target wards (2 surgical and 2 medical) at an Australian hospital. Patients admitted to these wards from December 2008 to November 2009, with at least one regularly prescribed medication, were eligible. The sample was stratified according to gender, season and ward. A medication chart audit identified medication omissions, and data were collected on gender, age, length of stay, comorbidities, medication history and clinical pharmacy review.ResultsOf the 288 medication charts audited, 220 (75%) had one or more medication omissions. Of the 15 020 medication administration episodes, there were 1687 omissions, resulting in an omission rate per medication administration episode of 11%. Analgesics and aperients were the most frequently omitted medications, with failure to sign the medication record and patient refusal, the main reasons for omission. Female gender (p < 0.001) and the number of medication administration episodes (p < 0.001) were statistically significant predictors of non-therapeutic medication omissions.Conclusion The high incidence of medication omissions suggests there is need for an agreed definition of medication omission and its inclusion as a reportable incident. Increasing medication reconciliation via implementation of the Medication Management Plan may also reduce the opportunity for error.

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Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011.
188
RESEARCH
Sharon L Latimer, RN, BN, MN, MAP (Health Care Research), GradDip Learning
and Teaching, Associate Lecturer, School of Nursing and Midwifery, Griffith
University, Logan Campus, Wendy Chaboyer, BSc (Nurs) (Dist), MN (Research),
PhD, Professor, and Director, NHMRC Centre of Research Excellence in Nursing
Interventions for Hospitalised Patients, Research Centre for Clinical and
Community Practice Innovation, Tony Hall, BPharm (Hons), AdvDip Clin Pharm
Teaching, DipMedSci (Palliative Care), Senior Lecturer, School of Pharmacy,
Griffith University, Gold Coast Campus, Gold Coast, Queensland
Address for correspondence: Sharon Latimer, School of Nursing and Midwifery,
Griffith University, Logan Campus, Southport Qld 4131, Australia.
E-mail: s.latimer@griffith.edu.au
Non-Therapeutic Medication Omissions:
Incidence and Predictors at an Australian Hospital
Sharon L Latimer, Wendy Chaboyer, Tony Hall
ABSTRACT
Background: The inconsistent definition of non-therapeutic
medication omissions, under-reporting, and a poor
understanding of their associated factors hamper efforts to
improve medication administration practices.
Aim: To examine the incidence of non-therapeutic medication
omissions among acutely ill medical and surgical adult patients;
and to identify the patient-, drug- and system-related predictors
of these omissions.
Method: A medication chart audit of 288 acutely ill adult medical
and surgical patients admitted to 4 target wards (2 surgical and
2 medical) at an Australian hospital. Patients admitted to these
wards from December 2008 to November 2009, with at least
one regularly prescribed medication, were eligible. The sample
was stratified according to gender, season and ward. A medication
chart audit identified medication omissions, and data were
collected on gender, age, length of stay, comorbidities,
medication history and clinical pharmacy review.
Results: Of the 288 medication charts audited, 220 (75%) had
one or more medication omissions. Of the 15 020 medication
administration episodes, there were 1687 omissions, resulting
in an omission rate per medication administration episode of
11%. Analgesics and aperients were the most frequently omitted
medications, with failure to sign the medication record and
patient refusal, the main reasons for omission. Female gender
(p < 0.001) and the number of medication administration
episodes (p < 0.001) were statistically significant predictors of
non-therapeutic medication omissions.
Conclusion: The high incidence of medication omissions
suggests there is need for an agreed definition of medication
omission and its inclusion as a reportable incident. Increasing
medication reconciliation via implementation of the Medication
Management Plan may also reduce the opportunity for error.
J Pharm Pract Res 2011; 41: 188-91.
INTRODUCTION
Patient safety is a priority for hospital administrators and
health professionals.
1-3
Medication administration is
central to contemporary patient management, and is the
second most frequently performed nursing activity in
many hospitals.
4,5
In Australian hospitals, medication
error is the second most frequently occurring incident,
with patient falls rating as number one.
6
Until recently,
little was known about the incidence of medication error
and omission. The Institute of Medicine’s report To Err
is Human: Building a Safer Health System estimated
that up to 98 000 patients die annually in US hospitals
because of medication errors.
2
In Australia, there are
approximately 190 000 medication error related hospital
admissions per year at a cost of $660 million.
6
In patient safety reports, medication administration
is identified as a high-risk activity, although how this
relates to medication omissions is less well known.
7
Risks
to patients’ include medication duplication, omission and
dosing errors.
7-9
Increased polypharmacy associated with
the ageing population, and chronic disease, further
compounds this issue.
10,11
Medication omissions are the
most frequent medication error,
with acutely ill patients
being vulnerable.
6,12
Medication errors are under-
reported, with omissions accounting for 2% to 79% of all
medication errors.
6,10,12
In recent Australian studies, 81%
of all identified medication errors are reported to be
omissions, with 86% of omitted medications placing
patients at some risk of harm.
8,13
These results are mirrored
internationally.
10,14
The aim of this study was to examine the incidence
of non-therapeutic medication omissions among acutely
ill medical and surgical adult patients; and to identify
patient-, drug- and system-related predictors of these
omissions.
METHOD
A medication chart audit was used to collect data on the
incidence and possible predictors of non-therapeutic
medication omissions. Ethics committee approval was
obtained from Griffith University and Gold Coast Hospital
Human Research Ethics Committes. Adult patients at the
450-bed Gold Coast Hospital were eligible if they were
admitted to the four target wards (2 medical and 2 surgical)
over the 12-month (1 December 2008 to 30 November
2009) study period.
Using an average length of stay of 3 days, it was
estimated that 7680 admissions would occur across the
four target wards during the study period. It was estimated
that a sample size of 288 would provide 15 000 to 22 000
medication prescriptions and provide sufficient
opportunities for medication omissions. The sample size
for multivariate regression analysis was calculated by
allowing nine cases per stratum, providing sufficient
power analysis. A random sample of 288 patients, stratified
according to gender, season and ward were used.
Inclusion criteria were patients aged 18 years and over;
admitted to one of the four target wards; and prescribed
at least one regular medication. Patients were only
included once in the sample and for patients with multliple
admissions, their most recent admission was included.
Prescriptions were excluded if they were: once-only and
variable dose medications; telephone orders; intravenous
and subcutaneous continuous infusions; pro re nata
(as required) and nurse-initiated medicines, because these
are not regularly prescribed medications.
Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011.
189
Figure 1. Medication classification of the 1687 identified medication omissions.
33%
17%
8.1%
6.9%
5.6%
5.5%
5.4%
5.3%
5.1%
3.5%
3%
1.8%
0.7%
0%
5%
10%
15%
20%
25%
30%
35%
A non-therapeutic medication omission was defined
as a medication dose not administered before the next
due dose. The absence of a signature or the presence of
a tick ( ) on the medication chart were defined as
omissions due to the lack of administration
accountability.
8
A tick ( ) is not an accepted abbreviation
of the organisation, nor is it one of the National Inpatient
Medication Chart’s (NIMC) omission codes. A
therapeutic medication omission was defined as a
medication not administered based on clinical decisions
documented in the medical notes. Therapeutic medication
omissions were not included in the analysis.
The study by Warne et al.
10
and the NIMC informed
the audit tool design. Eight NIMC codes (A = absent; F
= fasting; L = on leave; N = medication not available; R =
patient refused; S = self-administered; V = vomiting; W
= withheld) and three additional codes were adopted
(Nil = no reason or signature; Acc = no route access
[intravenous]; T = tick [ ] instead of a signature). Data
were collected on nine possible predictors: three patient-
related (age, gender, number of comorbidities), two drug-
related (medication history, medication administration
episodes), and four system-related (clinical pharmacy
review, length of stay, season, ward).
6-8,10,11
During data
collection, the medical records and clinical notes were
reviewed to determine if the identified medication
omission was supported by documented clinical
decision-making (e.g. aperients withheld due to
diarrhoea). If evident, the omissions were deemed
therapeutic and not included in the analysis.
The characteristics of the first medication omission
experienced by a patient were analysed (this type of
analysis was used in a similar study).
7
De-identified data
were entered into the Statistical Package for the Social
Sciences (version 17). Descriptive statistics were
performed to describe the sample and identify the
incidence of medication omission. A model building
approach was used to identify the significant predictors
(p < 0.05) of medication omissions. Chi-square analysis
was used to test for association between individual
variables and the outcome medication omission. All
significant variables from the chi-square analysis were
then entered as predictors in the multivariate logistic
regression analysis. Only variables that were significant
(p < 0.05) were then entered into a second multivariate
logistic regression analysis, to develop a parsimonious
predictive model of medication omission.
RESULTS
The randomly selected sample (n = 288) was drawn from
a population of 5654 patients admitted to the four target
wards during the study period. Two hundred and twenty
(76%) patients experienced more than one medication
omissions; more females (n = 122; 55%) than males (n =
98; 45%) comprised this group. The age range was 18 to
95 years (mean 61.3; SD 20.9) and half (n = 147; 51%)
were over 65 years of age. The highest incidence of
omissions (n = 116; 40%) occurred in this older age group
(Table 1).
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On average, patients had 2.8 comorbidities, with half
reporting more than 3 comorbidities (n = 146; 51%), and
the majority having up to 5 comorbidities (n = 256; 89%).
Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011.
190
Of the 2095 medications prescribed that resulted in
15 020 medication administration episodes, 1687 non-
therapeutic omissions were identified, representing an
omission rate per medication administration episode of
11% or an average of 5.8 (SD 7.9) omissions per patient.
The 1687 non-therapeutic medication omissions were
classified according to the MIMS (Figure 1).
Analgesics (simple analgesics and opiates) were the
most frequently omitted medications (33%) with
alimentary medications (17%) the second most frequently
omitted medications (Figure 1).
The characteristics of the first omission were
examined for statistical significance. There was strong
statistical significance (χ² = 57; df = 5, p < 0.001), between
the number of medication administration episodes and
an omission. Patients with more than 25 medication
administration episodes (n = 146; 66%) were more likely
to experience an omission compared to those with fewer
medication administration episodes. The number of
comorbidities did not increase the likelihood of an
omission (χ² = 2.9, df = 4, p = 0.6).
Of the drug-related factors, most patients
experiencing an omission did not have a medication
history (n = 169; 77%) completed by the clinical
pharmacist. However, there was no statistical significance
between completion of a medication history by the clinical
pharmacist and a medication omission (χ² = 0.5, df = 1, p
= 0.5). The absence of a signature or the use of an NIMC
code (n = 65; 30%) on the medication chart, were the
main reasons for the first medication omission. Patient
refusal (n = 55; 25%), medication unavailability (n = 38;
17%) and withholding a medication (n = 27; 12%) without
a documented clinical reason, were the subsequent
reasons for omissions. Of the patients requiring to fast
for a procedure, 5.9% (n = 13) had medications omitted
without a documented medical order. In 5.5% (n = 12) of
first medication omissions, the presence of a tick ( ) on
the medication chart was identified as omissions. Finally,
a lack of access, either intravenous or gastrointestinal,
accounted for 2.3% (n = 5) of first medication omissions
experienced by a patient.
Of the first omission experienced by a patient, oral
medications (n = 162; 74%) were the largest group, with
the remaining 26% (n = 58) of omissions distributed across
six other routes of administration. Intravenous (n = 24;
11%) and subcutaneous (n = 20; 9.1%) routes were the
second and third, routes omitted, with antimicrobials and
anticoagulants the main medications involved.
Of the system-related factors, patient’s length of stay
ranged from 1 to 31 days (mean 4.8; SD 4.7). For patients
experiencing more than one medication omissions, over
two-thirds (n = 150; 68%) had a length of stay of 3 days
or more (Table 1). The frequency of omissions were closely
distributed across the four seasons, with no statistical
association (χ² = 2.3, df = 3, p = 0.5) between medication
omission and season. The majority of patients (n = 182;
83%) experiencing an omission did not have their
medication chart reviewed by a clinical pharmacist. There
was no statistical significance between these factors (χ²
= 2.1, df = 2, p = 0.4).
The overall predictive model was statistically
significant (χ² = 102, df = 22, p < 0.001). Two independent
variables, gender and medication administration episodes,
were statistically significant in predicting the likelihood
of medication omission. Table 2 represents the results
for predicting the probability of a patient experiencing a
non-therapeutic medication omission.
This final predictive model was statistically significant
(c² = 69, df = 2, p < 0.001). When compared to males,
females were almost 3 times more likely (OR 2.9; 95%CI
1.5–5.3) to experience a medication omission. Medication
administration episodes increased the likelihood of a
patient experiencing a medication omission (OR 1.04
95%CI 1.01.1). For each additional medication
administration episode, a patient has a 4% increased
likelihood of experiencing a medication omission.
DISCUSSION
Medication omissions fall under the broad category of
medication errors. Recent studies report omission rates
per patient ranging from 26% to 79% and our study found
an omission rate per patient of 76%.
10,15
In our study, the
omission rate per medication dose was 11% suggesting
1 in every 9 doses were omitted. A finding supported by
recent studies.
8,10
In our study, analgesics and alimentary medications
were the most frequently omitted, possibly suggesting
pain and bowel management strategies at the research
site may need reviewing. These findings are supported
by studies from Australia and the UK.
8,10
Unexpectedly,
92 doses (5.4%) of subcutaneous anticoagulants
(heparin, enoxaparin) were omitted without a valid
documented clinical reason. These omissions are difficult
to explain, especially when the doses were refused by
the patient or withheld by the nurse. Current prescribing
practices, poor knowledge of potential patient harm, a
lack of patient understanding, and reduced reporting of
patient refusal may explain these results.
10
Drug unavailability has been reported as the foremost
reason for medication omission.
12,13,15
In our study, the
principal reasons for omissions were the absence of a
medication chart signature and patient refusal. During
data collection, the notation all medications
administered was frequently observed in the medical
notes, but the medication chart revealed numerous
omissions, making it difficult to ascertain which document
was accurate. The absence of a signature may in part be
a ‘failure to document’ due to distractions rather than a
genuine medication omission.
16
The major issues of
concern relate to an increased risk of patients receiving
additional medication doses, coupled with a lack of
administration accountability.
8
Our study supports the
development of visual reminders, such as Have you
signed your chart? stickers, to change clinician
behaviour.
17,18
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Journal of Pharmacy Practice and Research Volume 41, No. 3, 2011.
191
We also found that pharmacological and manual
thromboprophylactic measures were simultaneously
prescribed on the medication chart, with only one space
for the signature. If the signature was absent, it was
assumed both measures were omitted, which may not
have been the case. Implementation of the Venous
Thromboembolism NIMC with two separate orders for
pharmacological and manual thromboprophylactic
measures, will assist clinicians to know, with greater
certainty, which drugs have been administered.
19
Of the first medication omission experienced by a
patient, the intravenous route was the second most
frequent route of omission. A lack of intravenous access
was the reason medications were omitted via this route,
suggesting poor timely replacement of the intravenous
device by staff. Antimicrobials were mostly involved in
this route of omission.
The vast majority of patients and more than three
quarters of patients experiencing a medication omission
did not have a medication history completed by a clinical
pharmacist. Medication reconciliation reduces the
opportunity for medication errors, although accurate
information from health professionals and patients
impacts on the robustness of the reconciliation process.
Some studies report that clinical pharmacy services have
a direct impact on clinical and economic outputs, such
as reduced medication errors and patient mortality
rates.
4,20,21
Our study found low rates of clinical
pharmacist medication histories, but this variable was
not statistically significant. Despite this, implementation
of the Medication Management Plan will provide a
systematic approach towards medication reconciliation,
reflecting the Pharmaceutical Society of Australias
practice standards.
16,22
This strategy should increase
medication history completion rates by the
multidisciplinary healthcare team.
Of the data collected on the nine possible patient-,
drug- and system-related predictors, two significant
predictors of omissions were identified: medication
administration episodes and female gender. Medication
administration episodes were a statistically significant
predictor of omissions, i.e. as the number of medication
administration episodes per patient increased, so did the
likelihood of omission. Numerous contributing factors
have been identified and include polypharmacy;
prescribing practices; and system, individual and
organisational failures.
9,10,23
Gender too, was a statistically significant predictor
of medication omission with females experiencing an
increased likelihood of omissions. One-third of females
in our study were aged 65 years and over, with more than
80% having one or more comorbidities. These factors
often result in polypharmacy, and possibly higher rates
of omission.
9
This study had some limitations. Firstly, only one
research site was used, however, the sample size was
large compared to similar studies.
8,10,13
Secondly,
medications without a signature and those with a tick
( ) were assumed to have not been administered and
this may have not been the case. Finally, many of the
results are representative of the first medication omission
experienced by a patient with extrapolation to
subsequent omissions questionable.
In conclusion, the high incidence of medication
omissions suggests there is need for an agreed definition
of medication omission and its inclusion as a reportable
incident. Increasing medication reconciliation via
implementation of the Medication Management Plan may
also reduce the opportunity for error.
Acknowledgments
This research project was supported by the DBL Development Fund Grant to
the value of $10 000.
Sincerest thanks to Professor Ruth Endacott for allowing us to use her
medication omission audit tool as a basis for our audit tool design
Competing interests: None declared
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Received: 31 May 2011
Revisions requested after external review: 26 July 2011
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Accepted for publication: 1 September 2011
    • "Patient education about PIP and patient participation in their care, should occur during the initial nursing PI risk assessment and continue throughout the patient's hospitalization. Gender differences in the delivery of nursing care have been reported in the areas of cardiology (Poisson et al. 2010) and medication errors (Latimer et al. 2011). Our study found male participants were less frequently repositioned compared with females. "
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    Full-text · Article · Jul 2015
    • "Using 2011e12 Australian hospital admission data, of the 9.3 million separations it is estimated there are 230,000 medication related hospital admissions every year, costing the community approximately $1.2 billion annually (Roughead et al., 2013). Medication errors can occur during the phases of prescribing, dispensing, and administration, with system and human factors increasing the likelihood of an error or omissions (Evans, 2009; Latimer et al., 2011). Whilst medication administration is a routine task for nursing, it is becoming an ever increasingly complex activity. "
    [Show abstract] [Hide abstract] ABSTRACT: Medication safety is a significant issue. Whilst medication administration is a routine task, it is a complex nursing activity. It is recognised in the literature that medication related adverse events are most often related to systems failures associated with the complex process of medication administration. This paper examines student’s perceived effectiveness of an educational intervention, designed to demonstrate the complex and multidisciplinary factors of systems related failures in medication administration. The intervention was underpinned by adult and experiential learning concepts and used a problem-based learning approach. A series of short digital recordings were developed along with discussion points to illustrate multidisciplinary interactions involved in medication administration. A small sample of second and third year undergraduate nursing students (n=28) evaluated the effectiveness of the educational resource. Our findings suggest that such resources are effective in demonstrating the complexity of medication related error and were authentic to practice. An educational intervention using problem based learning afforded nursing students the opportunity to engage with the systems factors that contribute to medication errors. Interventions that highlight these factors may play an important role in raising awareness of these issues and encourage students to carry this knowledge into clinical practice.
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  • [Show abstract] [Hide abstract] ABSTRACT: Background Little is known about the influences on nurses’ decisions to withhold surgical patients’ oral medications pre and postoperatively or the degree to which decisions are consistent. The literature is devoid of information that clarifies whether or at what point withholding a particular oral medication may constitute a medication error. Purpose This study sought to redress this gap in knowledge and identify factors influencing nurses’ decisions about withholding surgical patients’ oral medications. Methods This interpretive study recruited a convenience sample consisting of nine nurses from surgical wards in public and private hospitals on the Gold Coast, Queensland and northern New South Wales to participate in individual interviews. Data were transcribed and analysed using inductive content analysis to identify common themes. Findings Three main themes illustrated important influences on nurses ‘decisions, including ward culture, nurses’ perceptions of their roles and patient factors. Conclusions The complex issues surrounding nurses’ decisions when withholding surgical patients’ oral medications are identified in this research. The findings will help to inform quality and safety in future medication management and lead to higher quality and safer patient care.
    Article · Jul 2013
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  • undefined · undefined
  • undefined · undefined
  • undefined · undefined