Omitted and delayed medicines: the perils of paper prescription charts

Barking, Havering and Redbridge University Trust (BHRUT) is a large acute hospital operating from two main sites in North East London, which serves approximately 40% of 2 million residents. Patients admitted to these hospitals have medicines prescribed that play a vital role in maintaining health, preventing illness, managing chronic conditions and curing disease. Medicines have been proven to be the most common intervention utilised in healthcare. Failure to administer prescribed medicines to these patients has the potential to cause significant harm and increase the length of hospital stay.

Omitting doses of prescribed medicines is a common medication error in hospitalised patients. Reasons for omission can be medication unavailability, ineffective communication and inadequate documentation of administered medications. The trust’s annual Safe Medicines Practice Group (SMPG) report for 2020–2021 highlighted events involving medicines being administered late or omitted altogether as prevalent among all divisions in the trust. Medicines omitted or delayed include critical medicines such as antibiotics, anticoagulants, antidiabetics, anti-Parkinsonian drugs, immunosuppressants and anticonvulsants. 

There are multiple points within the patient’s care for medications to be omitted or delayed owing to medications not being transferred with patients, not being available and not being administered in a timely manner. Paper inpatient prescription charts are currently utilised at the trust and the process is reliant upon a nurse or midwife reading the chart, administering and signing for the medication with a high chance of omissions or delays. If a medication is not given as prescribed, the nurse or midwife must record the appropriate code for omission in the administration box, initial and, where applicable, document in the nursing notes as per the organisation’s policy. An electronic prescribing and medicines administration (EPMA) solution would potentially negate some of the issues experienced with current paper processes by being more legible, legally valid, highlighting when medications are due for administration, linking to pharmacy stock control systems and other associated benefits. 

Obtaining an evidence-based perspective of the current medication practices within the trust will aid in quantifying the expected benefits realisation of implementing EPMA. As part of determining the potential benefits, baseline data of omitted and delayed doses of medication in BHRUT was collected and analysed.

The audit utilised a data collection form created on Microsoft Excel to collect the required data. The data collection tool was split into three main sections: ward level, chart level and medication level. A pilot study was conducted on a ward within the trust to confirm the validity and reliability of the data collection tool. The data collection tool was tested, amended and repiloted on another ward on a different hospital site. The team also decided upon a standard methodology to reduce auditor bias. Terminology was developed using standard phrases so additional information entered was the same and would aid in data analysis at a later stage. The team was split so that there would always be a clinical team member (nurse or pharmacist) with a non-clinical team member (project support officer) if required. This was done so that any clinical questions raised by the non-clinical team member while auditing could be easily addressed. 

The data collection was carried out from 13 July 2021 to 12 August 2021 at both sites by four members of the EPMA team. All data collected were collated, the total number of omitted and delayed doses were calculated and the reasons given for medications being omitted or delayed were identified. A total of 772 paper prescription charts were reviewed across 35 wards with a total of 8,638 medicines prescribed (7,290 regular medicines and 1,348 STAT medicines). A total of 2,664 (37%) regular medicines and 100 (7%) STAT medicines were either omitted or delayed. Around 5,460 individual medication doses were omitted or delayed. A total of 839 (15%) doses of the 5,460 doses of medicines omitted or delayed were critical medicines. Of the 5,460 omitted/delayed doses, 2,362 (43.3%) had a recognised prescription chart code for omission and, where applicable, a documented reason in the nursing notes. The total time taken to find 772 charts by four auditors was approximately 12 hours.

The trust has an ongoing implementation plan as part of medicine management for sessions with nurses and midwives on the individual components of the prescription chart, with reference to the guidance for recording medicines administration and the importance of critical medicines and the escalation pathway for unavailability of critical medications. Additionally, recommended changes from the audit to the paper prescription chart codes have been approved and are now in place within the organisation on the updated paper prescription charts. The trust has also introduced a Self-Administration of Medicines (SAM) policy to allow patients to take their own medications while in hospital, supporting a philosophy of allowing patients to participate in their own care and make decisions about their treatment in partnership with the wider multidisciplinary team.

The longer term vision is for the trust to implement an EPMA solution to reduce the number of omitted and delayed doses, improve documentation and drive excellent patient care.