1. Reducing Omitted Doses through Audit
Ruth Brown
Quality and Governance Pharmacist
Kent Community NHS Foundation Trust

2. Introduction
Describe Kent Community Health NHS Foundation Trust
Present the development of an omitted dose audit
Present a brief summary of the findings from five years of collecting audit data.

3. Kent Community NHS Health Foundation Trust
Kent Community NHS Foundation Trust (KCHFT) serves a population of 1.4 million across Kent, and 600,000 in East Sussex and London with a staff of 5,000.
We provide wide-ranging NHS care for people in the community, in a range of settings including people’s own homes; nursing homes; health clinics; community hospitals; minor injury units and in mobile units.

4. Background
NPSA Rapid Response Alert Reducing harm from omitted and delayed medicines in hospital
In response an omitted dose audit was designed and conducted in 2011 in 12 community hospitals across Kent.
Audit Aims:
• to ascertain current medication omission rates
• to ensure appropriate action is taken subsequent to incidents
• to encourage incident reporting related to omission or delay
• to reduce harm from omitted and delayed medicines.
Decision made to collect omitted only as difficult and less relevant.

5. Methodology 2011
All pharmacy staff working in community hospitals collected the data from all charts from each ward.
14 days medicines administrations were checked for each patient.
Omitted dose rate calculated from total administrations that should have been given.
Risk of harm calculated from UKMi critical medicines list (2010, revised in 2016)
Definition of omitted dose in KCHFT is did not include omissions when the omission was justified when omission medically justified or taking into account the patients current clinical condition.
And patient refusal also discounted
Picking up on empty boxes with no codes

6. Methodology 2011 Assessing risk of harm using UKMi definitions
Low risk: Nil or negligible patient impact with nil or minor intervention required; no increase in length of stay.
Moderate risk: Significant short-term patient impact with moderate intervention required; increase in length of hospital stay possible.
Significant risk: Significant or catastrophic long-term patient impact with ongoing intervention required; long increase in length of stay possible.
Built up the expertise and knowledge over the years through keeping a database.

7. 2011 Findings Omitted dose rate was 1.76% with and without codes
Problems with lack of consistency of drug chart omission codes and lack of consistency with multiple staff collecting data
Nursing staff lack of knowledge regarding critical medicines
Good practice noted to be reviewing the drug charts after the medicine rounds in some wards with low omitted dose rates

8. Target setting in 2011
The initial omitted dose rate targets in 2011 were set at:- Target: The omission rate for medication omissions (with and without codes) for a Community Hospital Ward to be less than 1.5 % Target: The omission rate for medication omissions (without codes) for Community Hospital Ward to be less than 1.0% Target: The omission rate for medication omissions (with and without codes) in a Community Hospital where the risk is significant to the patient to be less than 0.5%

9. Methodology changes since 2011
One pharmacist responsible for data collection each year
Targets changed to 0% omitted dose i.e. zero tolerance. A hard line was taken.
Target: 100% peer checking
However, acknowledged the factors beyond our control

10. Omitted dose by risk
Discovered inverse relationships between incident reporting and omitted dose rate. Possibly demonstrating that error reporting culture is beneficial

11. Percentage of risk errors from omitted doses
The percentage of ‘significant risk’ errors: 0.25% in % in % in Increase The percentage of ‘moderate risk’ error: 0.24% in % in % in 2015 Decrease The percentage of ‘low risk’ error: 0.92% in % in % in 2015 Decrease
Important to note that small number of omitted doses can significantly alter the % error rate.

12. Quality Improvement Drug chart standardised across the whole trust
Medicine charts reviewed after drug rounds adopted as good practice for all wards. Peer checking form introduced in 2013 to aid nursing staff with the process. Significant increase in peer checking shown in 2015 with almost half the wards peer checking % of the time and the rest 50-90% of the time.
Management of staff with responsibility/ accountability emphasised
Datix reporting encouraged
Twice daily delivery requested in tender specification for new supplier of medicines to hospitals
So much has changed and these are just some examples including the promotion of datix reporting.
The use of agency does increase the omitted dose rate.

13. Quality Improvement
Low molecular weight heparins given once a day at the same time each day.
Parkinson’s patients are treated separately with additional reminders for nursing staff to administer medicines, for example, mobile phone alarms.
Weekly alendronic acid is administered by night staff before breakfast.
Process put in place to make sure that patients who are off the ward (for example, renal dialysis) still receive their medication.
An agency nurse leaflet has been introduced to convey important information around medicines.

14. Omitted dose rate 2011 – 2015
With and without codes validity of red flag reports

15. For further information contact: heather.habing-ridout@nhs.net
Thank you!
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