AHRQ Patient Safety Network ▲ Reducing unacceptable missed doses: pharmacy assistant–supported medicine administration.

AHRQ Patient Safety Network

Adding the support of a pharmacy assistant led to marked decrease in missed medication doses in a hospital in England.Int J Pharm Pract. 2015 Jan 28; [Epub ahead of print].

Reducing unacceptable missed doses: pharmacy assistant–supported medicine administration.

Baqir W, Jones K, Horsley W, et al. Int J Pharm Pract. 2015 Jan 28; [Epub ahead of print].

Omitted or delayed medication doses occur frequently in hospitals. Although the majority of thesemedication 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.

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