Reducing unacceptable missed doses: pharmacy assistant–supported medicine administration.
Approach to Improving Safety
Setting of Care
Omitted or delayed medication doses occur frequently in hospitals. Although the majority of these medication administration errors do not harm patients, some have serious effects and contribute to patient deaths. Recent interventions, such as barcode medication administration systems, may help mitigate this problem, but the evidence to date has been mixed on how electronic systems affect omitted or delayed doses. This study evaluated the strategy of providing the support of pharmacy assistants to nurses during medication administration on an acute care ward at a district hospital in England. The intervention group was compared to both intraward and interward control groups. Over the course of 2 weeks, unacceptable omitted medication doses were observed in 18.5% of patients on the control ward, versus only 1.1% of patients on the wards with pharmacy assistant support. While these findings suggest a possible robust solution to this common problem, major limitations to this study include the brief study period and the lack of an economic analysis to support the feasibility of this approach.