Trained pharmacy teams in the United Kingdom have undertaken a multi-centre study to determine the prevalence, nature and predictors of omitted doses in psychiatric hospitals. Among 444 inpatients, 2,717 dose omissions were reported from 18,664 scheduled doses, a raw omission rate of 14.6% (95% CI 14.1–15.1). Medicines targeting the central nervous system were 55% less likely to be omitted (odds ratio 0.45; 95% CI 0.40–0.52), while non-oral scheduled medication doses were more likely to be omitted compared to orally administered medications. The study then used sound criteria to classify omitted doses as ‘time critical’ or ‘preventable’, observed at rates of 19.3% and 34.5%, respectively. Additionally, it was more than twice as likely for ‘preventable’ omitted doses to occur for ‘time critical’ medications compared to non-time critical medications. This study identifies ‘preventable’ omitted doses as an essential target for the development of quality improvement interventions aiming to decrease the burden of omitted medication doses in psychiatric hospitals. Further details of this study can be accessed here.

Contributed by Australian Medication Safety Services Associate – Isabella Singh