1. Omitted, Delayed or Early Medication Doses

2. Background
NPSA alert in February 2010 raised potential harm to patients as a result of delayed or omitted medications
All organisations looking after inpatients were required to identify critical medicines and ensure medicines management

3. Guidance Ideally doses should not be omitted.
If interval between doses is too close, there is also risk of increased side-effects or toxicity (e.g. Lithium and paracetamol).
Some drugs have specific minimum dosage intervals (e.g. paracetamol 4-hourly).

4. Guidance
Clinical judgement and/or advice from prescriber or pharmacy should be used when deciding whether to administer a delayed or early dose, consider:
Type of medication – are actions or side-effects problematic if given earlier or later (e.g. insomnia with SSRIs).
If plasma levels need to be taken and effect on result
Interactions, or effects of food on medication. (e.g. flucloxacillin on empty stomach).

5. Guidance
If other considerations have been taken into account, the following can guide whether to administer an early or delayed dose:
Frequency
Delayed dose can be given if next dose not due for at least:
Early dose can be given if the previous dose was not given within at least:
Four times a day
3 hours
Three times a day
4 hours
Twice a day
6 hours
Once a day
12 hours

6. Exceptions Lithium is an important exception due to lithium toxicity:
Once daily dosing
Delayed dose – must be given within 6 hours of prescribed dose
Early dose – must be at least 18 hours since the previous dose.
Twice daily dosing
Delayed dose – must be given within 3 hours of prescribed dose
Early dose – must be at least 9 hours since the previous dose.

7. What to do next…
If delayed, the borders of the administration box should be thickened with a pen to highlight the dose has not yet been administered.
After a final decision, the administration box should be completed with either initial of nurse administering the dose, or the relevant omission code.
Nurse responsible for initial decision must hand over to next shift if a decision to administer or omit has not been made.
If a decision to administer early, the time must be written next to nurse signature. Reason for early administration must be recorded in the notes.