The significance of dose omissions in the paediatric intensive care unit. Issue 5 (22nd April 2012) - Isaac, R
Abstract : Objectives: To quantify the number of doses omitted on paediatric intensive care unit (PICU) and compare to published data. To ascertain the reasons and clinical significance of these dose omissions. Method: A retrospective review of the medication administration records (MAR) on PICU and a literature review of missed doses was undertaken. Doses omitted from regularly prescribed medicines; continuous infusions and stat doses were included in the study. Reasons for omissions were recorded from the MAR by noting the number assigned by staff or from written documentation in patients' medical notes. A multidisciplinary panel was asked to give their opinion of the clinical significance of omission using the National Reporting and Learning Scheme scoring system. The severity classification assigned by the panel was compared with the UK MI tool to support the NPSA Rapid Response Report Reducing Harm from omitted medicines in hospital and the Trust local implementation list published postanalysis. Results: There were 1995 prescribed doses for 18 patients, of which 129 (6.5%) doses were omitted. Authorised that is doctors request, awaiting levels or no access to give medicine accounted for 34 (26%) omissions. Of the 95 unauthorised omissions, 87 (67% total omitted doses) were not assigned justification for withholding the dose on the MAR or in the medical notes. There was no documentation in the administration box or in the medical notes on five occasions and it could not be confirmed if dose given or not. On four occasions the drug was not available in the clinical area. Anti-infective drugs were the highest group of drugs omitted followed by electrolytes. Lack of access was a common indication for electrolyte omission. Oral and naso-gastric routes were omitted on 81 occasions, and 48 (37%) intravenous doses were omitted. None of the omissions were reported via the Trust medication incident system. The panel assigned severe potential harm to 26 (20%) of the omissions, and moderate potential harm to 40 (31%). All the potential severe harm group were drugs to be administered via the intravenous route. Anti-infective, diuretic and corticosteroid omissions were considered as the most serious unauthorised medication exclusions. The panel expressed difficultly in deciding if a withheld dose was appropriate. The 'no patient risk impact' is quoted in the UKMI tool for anti-infective or intravenous diuretics whereas the panel considered the highest patient risk impact. Corticosteroid omission in the UKMI tool is only considered significant when indication is post-transplant, whereas the panel considered omission in a premature infant for lung disease to be of concern. Diuretics are not included on the local Trust list of drug that requires timely administration in relation to prescribed time. Conclusion: This small study shows medicines omission rates on PICU are slightly lower than quoted in the literature. However, improvement in the documentation for withholding doses is required on PICU to ensure appropriateness and to assign potential significance to patient harm.