Measuring and Describing Dose Omissions using an Electronic Medication Management System

Background Omitted doses are the most common cause of medication errors in hospital. The impact of an electronic medication management system (eMMS) on rates of omitted doses is unclear. Aim To determine the rate of omitted doses in inpatients using MedChart and to identify non‐valid omissions involving high‐risk medications. Method Retrospective reports were generated using eMMS and omitted doses were identified across inpatient wards (except the ED) at a tertiary hospital over a 2‐week period in 2011. Omissions were classified to highlight non‐valid omissions and the prevalence of high‐risk medications. Results were compared to voluntary incident reports for the same period and institutional data from 2001. Results 7.5% (5308//70 774) of doses were recorded as omitted, mirroring 2001 results (7.6%). Non‐valid omissions accounted for 11% (571/5308) of total omissions. ‘Medication unavailable’ was the reason for omission in 19% (111/571) of non‐valid omissions. 24% (137/571) involved high‐risk medications, with anti‐infectives the most commonly missed group (52%, 71/137). Only 2 omitted doses were reported in the voluntary system. Conclusion Although eMMS did not reduce the rate of omitted doses, there was a decrease in ‘missed’ doses. High‐risk medications were prevalent in non‐valid dose omissions. Omitted doses were significantly under‐reported via the voluntary system.