Non-therapeutic omission of medications in acutely ill patients

Nursing in Critical Care

Volumn 15, Issue 3, 2010, Pages 112-117

  Warne, Siobhan ^a   Endacott, Ruth ^a   Ryan, Helen ^b   Chamberlain, Wendy ^c   Hendry, Julie ^d   Boulanger, Carole ^e   Donlin, Nicola ^d  

^a UNIVERSITY OF PLYMOUTH   (United Kingdom)

^b YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST   (United Kingdom)

^c TAUNTON AND SOMERSET HOSPITAL   (United Kingdom)

^d DERRIFORD HOSPITAL   (United Kingdom)

^e ROYAL DEVON AND EXETER HOSPITAL   (United Kingdom)

Author keywords

Acutely ill patients; ICU outreach; Medication omission; Patient safety; Point prevalence survey

Indexed keywords

ACUTE DISEASE; ARTICLE; CHI SQUARE DISTRIBUTION; DIAGNOSIS RELATED GROUP; DOCUMENTATION; HUMAN; INTENSIVE CARE; LENGTH OF STAY; MEDICAL RECORD; MEDICATION ERROR; MOTIVATION; NONPARAMETRIC TEST; NURSING; NURSING EVALUATION RESEARCH; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PREVALENCE; PROSPECTIVE STUDY; RISK MANAGEMENT; STATISTICAL MODEL; STATISTICS; TREATMENT REFUSAL; UNITED KINGDOM;

ACUTE DISEASE; CHI-SQUARE DISTRIBUTION; CONTINUITY OF PATIENT CARE; CRITICAL CARE; DOCUMENTATION; ENGLAND; HUMANS; LENGTH OF STAY; LOGISTIC MODELS; MEDICATION ERRORS; MOTIVATION; NURSING AUDIT; NURSING EVALUATION RESEARCH; NURSING RECORDS; OUTLIERS, DRG; PREVALENCE; PROSPECTIVE STUDIES; RISK MANAGEMENT; STATISTICS, NONPARAMETRIC; TREATMENT REFUSAL;

EID: 77956636563     PISSN: 13621017     EISSN: 14785153     Source Type: Journal    
DOI: 10.1111/j.1478-5153.2010.00365.x     Document Type: Article

References (30)

1. Al-Tajir GK, Kelly WN. (2005). Epidemiology, comparative meth-ods of detection and preventability of adverse drug events. Annals of Pharmacotherapy; 39: 1169–1174.
2. Balas MC, Scott LD, Rogers AE. (2004). The prevalence and nature of errors and near errors reported by hospital staff nurses. Applied Nursing Research; 17: 224–230.
3. Bion JF, Heffner J. (2004). Improving hospital safety for acutely ill patients. A Lancet quintet. I: current challenges in the care of the acutely ill patient. Lancet; 363: 970–977.
4. Chaboyer W, McMurray A, Johnson J, Hardy L, Wallis M, Chu FY. (in press). Bedside handover: quality improvement strategy to ‘transform care at the bedside’. Journal of Nursing Care Quality; (accepted October 2008). Doi:10.1097/01.NCQ.0000338953.64134.23.
5. Cohen E, Botti M, Hanna B, Leach S, Boyd S, Robbins J. (2008). Pain beliefs and pain management of oncology patients cancer. Nursing; 31: E1–E8.
6. Commission for Healthcare Audit and Inspection. (2007). The best medicine–The management of medicines in acute and specialist trusts. London: Commission for Healthcare Audit and Inspection.
7. Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. (1997). Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Critical Care Medicine; 25: 1289–1297.
8. Dean BS, Allan EL, Barber ND, Barker KN. (1995). Comparison of medication errors in an American and a British hospital. American Journal of Health-System Pharmacy; 52: 2543–2549.
9. Department of Health (2006). Safety first –A report for patients, clinicians and healthcare managers. London: Department of Health.
10. Endacott R, Boulanger C, Chamberlain W, Hendry J, Ryan H, Viner JE. (2006). Missed medications and clinical cues in patients admitted unexpectedly to intensive care [Abstract]. Intensive Care Medicine; 32: S12.
11. Endacott R, Eliott S, Chaboyer W. (2009). An integrative review and meta-synthesis of the scope and impact of intensive care liaison and outreach services. Journal of Clinical Nursing; 18: 3225–3236.
12. Endacott R, Warne S, Boulanger C, Chamberlain W, Hendry J, Ryan H, Viner J. (2007). Missed medications in acutely ill patients [Abstract]. Intensive Care Medicine; 33(Suppl 2): S117.
13. Ho CYW, Dean BS, Barber ND. (1997). When do medication administration errors happen to hospital inpatients? International Journal of Pharmacy Practice; 5: 91–96.
14. Hogan H, Olsen S, Scobie S, Chapman E, Sachs R, McKee M, Vincent C, Thomson R. (2008). What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management? Quality and Safety in Health Care; 17: 209–215.
15. Kane-Gill S, Rea SR, Verrico MM, Weber RJ. (2006). Adverse-drug-event rates for high-cost and high-use drugs in the intensive care unit. American Society of Health-System Pharmacists; 63: 1876–1881.
16. Kester L, Stoller JK. (2003). Prevalence and causes of medication errors: a review. Clinical Pulmonary Medicine; 10: 322–326.
17. Kopp BJ, Erstad BL, Allen ME, Theodorou AA, Priestley G. (2006). Medication errors and adverse drug events in an intensive care unit: direct observation approach for detection. Critical Care Medicine; 34: 415–425.
18. Lawler C, Welch SA, Brien JAE. (2004). Omitted medication doses: frequency and severity. Journal of Pharmacy Practice and Research; 34: 174–177.
19. McMillan TW, Hamley J, Pullar T. (1994). Compliance with prescribed medicines in general medical and surgical wards. British Journal of Clinical Practice; 48: 302–303.
20. National Patient Safety Agency (NPSA). (2007a). Safer care for the acutely ill patient‘: Learning from serious incidents PSO/5. London: National Patient Safety Agency. www.npsa.nhs.uk (accessed 23/06/07).
21. National Patient Safety Agency (NPSA). (2007b). Safety in doses: Medication safety incidents in the NHS. The fourth report from the Patient Safety Observatory (PSO/4). London: NPSA.
22. National Patient Safety Agency. (2008). Patient safety incident reports in the NHS: National Reporting and Learning System Data Summary. Issue 9. England. Workbook to accompany summary data accessed at: http://www.npsa.nhs.uk/nrls/patient-safety-incident-data/quarterly-data-reports/(accessed 17/11/08).
23. Nettleman MD, Bock MJ. (1996). The epidemiology of missed medication doses in hospitalized patients. Clinical Performance and Quality Health Care; 4: 148–153.
24. NHS Institute. (no date). Releasing time to care: the productive ward. http://www.institute.nhs.uk/quality_and_ value/productivity_series/productive_ward.html (accessed 27/01/09).
25. Olsen S, Neale G, Schwab K, Psaila B, Patel T, Chapman EJ, Vincent C. (2007). Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Quality & Safety in Health Care; 16: 40–44.
26. Paice JA, Noskin GA, Vanagunas A, Shott S. (2005). Efficacy and safety of scheduled dosing of opioid analgesics: a quality improvement study. Journal of Pain; 6: 639–643.
27. Paice JA, Toy C, Shott S. (1998). Barriers to cancer pain relief: fear of tolerance and addiction. Journal of Pain and Symptom Management; 16: 1Y9.
28. Reason J. (2004). Beyond the organisational accident: the need for ‘‘error wisdom’’ on the frontline. Quality & Safety in Health Care; 13(suppl II): ii28–ii33.
29. World Health Organization. (2007). Communication during patient hand-overs. Patient Safety Solution; 1: http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf (accessed 17/01/09).
30. World Health Organization (WHO). (2008). Global patient safety: research priorities for patient safety. http://www. who.int/patientsafety/research/activities/priority_setting/en/index.html (accessed 27/01/09).