Retrospective and Observational Analysis of Missing and Delayed Medications at a Large Community Teaching Hospital

Medication errors are a national concern that can compromise patient care and increase health-care costs. The American Society of Health-System Pharmacists (ASHP) defines omission errors as the failure to administer an ordered dose to a patient before the next scheduled dose. Wrong time errors are defined as the administration of medication outside a predefined time interval from its scheduled administration time. These errors can result in serious harm or even death. Pharmacists play a significant role in preventing medication errors. Pertaining to omission errors and wrong time errors, ASHP recommends that pharmacists ensure medications are delivered to the patient-care area in a timely fashion after the receipt of orders. In addition, pharmacists should review medications that are returned to the department to reveal system breakdowns. Because nurses are directly involved in patient-care activities including the administration of medications, they also play a large role in the prevention of medication errors. In order to prevent missing or delayed medications, communication is essential between nursing and pharmacy. Missing and delayed medications have been identified as a growing concern among providers and nurses at Carilion Roanoke Memorial Hospital, which warranted a closer investigation of the entire medication delivery process. Although missing and delayed medication doses are a common type of medication error, it is often difficult to determine the cause of these errors. Doses are often sent again without trying to locate the original dose in order to prevent delays. The purpose of this study was to determine underlying causes for missing medications hospital-wide through prospective analysis, as well as identify reasons for medication delays specific to the pediatric population through retrospective analysis.Doctor of Pharmac