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Specialist Pharmacy Service Medicines Use and Safety

Omitted and Delayed Medicines

A collaborative audit of omitted and delayed

anti-microbial doses in acute, community and

mental health settings

Jane Hough and Jane Nicholls

Medicines Use and Safety Division NHS Specialist Pharmacy Service

May 2012 and reviewed May 2015

© Specialist Pharmacy Services

Medicines Use and Safety

A collaborative audit of omitted and delayed anti-microbial doses – V1.1 May2015 (JH/JN)

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A collaborative audit of omitted and delayed anti-microbial doses, in acute, community and mental health care settings

Executive Summary 1. 19,655 patients from 54 trusts were reviewed over a 24 hour period. 6062 patients were

prescribed parenteral or enteral antimicrobials and 21,825 doses representing 8748 antimicrobial prescriptions were audited.

2. The audit identified an average omission rate of 5.3% (1151/21825) for prescribed antimicrobial doses. 13.2% (802/6062) of audited patients missed at least one dose of a prescribed antimicrobial.

3. The existence of any one of the following made a dose twice as likely to be missed

First dose

First dose not written up as a “stat” dose

Antimicrobial not held as ward stock

4. In the 45 acute trusts no reason was recorded for 29% of the omissions, an ‘other’ reason for 26% and antimicrobial ‘not available’ for 19%. Refusing a dose and no route of administration available both reported 12% of omissions and patient away from the ward only 3% of omissions.

5. 19% of the doses recorded as being ‘unavailable’ were actually available on the ward at the time the dose was due to be administered.

6. When followed up by data collectors, doses had been given but not signed for in at least 29% of the cases where the administration records had been left blank.

7. 6.3% (565/8923) of doses were overdue at the time the audit took place. 7.7% (467/6062) patients were overdue an antimicrobial dose at the time of the audit.

8. Electronic prescribing sites reported the same omission rate as traditional prescribing sites but they had a higher proportion of delayed doses (16% v 5.4%).

9. A much smaller number of community health and mental health patients were audited compared to acute trusts and fewer antimicrobials were prescribed. 16.7% of mental health patients missed doses and more often through non-availability than in acute trusts. However mental health patients were found not to refuse doses more frequently than acute trust patients.

10. There were differences in omission rates and reasons for omission between the acute trust care areas; some care areas with high omission rates had small data sets. Omission rates were relatively high for care of the elderly patients and low for critical care and paediatric patients.

11. The issues influencing delayed and omitted antimicrobial doses are multifactorial, complex and require multi-disciplinary solutions. Trusts should identify specific issues locally and develop solutions with nursing and medical colleagues to ensure prescribing is clear and takes account of routes of administration available and that supply is slick and intuitive and nursing staff understand the importance of administering critical medicines on time and are helped to prioritise medicines within their other competing tasks. In general documentation needs improving and traditional methods of restricting access to antimicrobials needs to be reviewed.



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Recommendations to Trusts Trusts are recommended to review their data locally and to compare to the overall results to identify their areas of good practice and those with room for improvement. The overall results suggest trusts should in general:

1. Raise awareness of the importance of prescribing and administering critical medicines in a timely manner amongst all healthcare professionals and ensure there are clear lines of responsibility

2. Review supply processes particularly for first doses. Supply processes need multi-professional input, need to be instinctive and take account of current situation e.g. outliers, accessing a remote Emergency Drug Cupboard

3. Traditional methods of controlling access to restricted anti-microbials such as ward stock lists may need to be reviewed

4. Adopt the Department of Health’s Start Smart and Focus approach

5. Put systems in place to help nursing staff locate antimicrobials on the ward area by e.g. using productive ward techniques, aide memoirs

6. Ensure that omitted doses are followed up – particularly those recorded as “not available”; as these may be on the ward and the nurse has been unable to locate

7. Work with nursing colleagues around poor documentation including “blanks” which is covered in Nursing and Midwifery Council (NMC) Standards for Medicines Management (Standard 8 point 2.10)

8. Be aware that solutions for one care area may not be as successful in another care area so engagement with nursing staff and understanding the difficulties they face is key (particularly competing priorities; competence to administer and familiarity with the medicine)

9. Encourage medical staff to communicate (including to the patient) when prescribing an antimicrobial (or any other medicines on local critical medicines lists); ensuring the prescription is appropriate for the route(s) of administration that are available and that it is legible (and includes indication and duration where necessary)

10. Multiple refusals of doses should be reported to prescribers for a review of the prescription

11. Revisit how well allergy status is documented particularly where policy states this needs to be recorded before doses (especially penicillin containing antimicrobials) are given

12. Revisit Nil By Mouth policies to ensure all staff give consistent advice

13. Provide guidance on timings of future doses where administration times have become out of synch with prescribed times

14. Share audit results and good practice

15. Embed delayed and omitted doses as an organisational responsibility



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A collaborative audit of omitted and delayed anti-microbial doses, in acute, community and mental health care settings

1. Aim

The aim of the collaborative audit was to gather data which would help to quantify the extent of omitted and delayed enteral and parenteral anti-microbial doses and the range of reasons for these in all care settings; which could then be used to target areas for improvement.

2. Objectives:

To quantify the number of omitted and delayed doses of antimicrobials. To collect information on the reasons for doses being omitted To attempt to validate “not available” & “blank administration record” reasons To examine the differences between first dose omissions and those of other doses.

3. Background

The National Patient Safety Agency (NPSA) issued a Rapid Response Report on Reducing harm from omitted and delayed medicines in hospital (RRR009) in February 2010

1. Between September 2006 and

June 2009 the NPSA received reports of 27 deaths, 68 severe harms and 21,383 other patient incidents relating to omitted or delayed medicines. Of the 95 most serious incidents, 31 involved anti-infectives. The RRR lists a number of actions organisations needed to complete by 24

th February 2011.

One action was for each organisation to identify a list of critical medicines where timeliness of administration is crucial. The list should include anti-infectives amongst other medicines. Another action was to carry out an annual audit of omitted and delayed critical medicines and to ensure that system improvements to reduce harm from omitted and delayed medicines are made. A multicentre collaborative point prevalence audit was designed to allow organisations to benchmark themselves; to identify specific areas of weakness in their current practices and use these to inform system improvements. Successes in areas of good practice would be shared to support those doing less well. Trusts would be able to use or adapt the methodology to undertake repeat audits in the future to measure improvement. Because a collaborative audit on delayed and omitted doses of all prescribed medicines would have been unwieldy it was decided to focus the audit on antimicrobials which are prescribed in all care settings and all sectors of care and the NPSA had recommended should appear on organisations lists of critical medicines.

4. Methodology

Trusts from the four original SHAs (East of England, London, South Central and South East Coast) in the East and South East England geography were invited to participate in the collaborative audit. 45 acute trusts, four community health and five mental health trusts submitted data. Participating trusts are listed in Appendix A. The point prevalence audit was carried out over one 24 hour period on a day of choice of the participating Trusts in December 2010. Mondays were avoided to mitigate against variations arising from different supply arrangements at weekends; and Fridays were generally too busy a day for data collection.

On the nominated day antimicrobials that had been prescribed to be administered over the preceding 24 hour period were reviewed and data was collected on the form provided (this had previously been piloted). Detailed guidance was also provided on data to include and how to record it. Data collection forms and guidance notes can be found in Appendix B. Omitted doses were allocated to one of six categories describing the reason for omission as recorded on the drug chart.



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Categories used to describe reasons for omission

Reason dose omitted Explanation

Away The patient was away from the ward at the time the antimicrobial dose was due Blank Nothing had been recorded in the administration box by the nurse Not available The antimicrobial was reported on the drug chart as not being available on the

ward for administration No route The prescribed route of administration was not available for use e.g. no

intravenous access Other Reason for omission was not covered by any of the other categories but an

explanation had been recorded e.g. NBM Refused Patient refused to take the dose

The data collectors attempted to follow up the reasons for omissions recorded as “not available” and “blank”; by looking for the unavailable antimicrobial on the ward and estimating if it would have been there at the time the dose was due and for blanks discussing with the nurse (if he/she was on duty at the time of data collection) whether he/she had given the dose but had forgotten to sign the administration record. Local audit co-ordinators ensured consistency of data collection and entered data onto the organisation’s master spread sheet. This had been populated with embedded formula to provide some initial local data that could be used to help close the NPSA Rapid Response. Master spread sheets from the participating organisations were returned centrally for collation, review of data and data cleansing prior to further analysis. Statistical analysis used the Chi Square test where appropriate.

5. Definitions used in the audit were:

Definition

Omitted Dose A dose that had not been given before the next dose was due Delayed Dose A dose that was overdue at the time of the audit – this was measured in hours

(underestimating the actual duration of the delay but identifying the number of doses that had been delayed)

First Dose The first dose of a course of antimicrobial therapy. Including those doses prescribed as stat doses.

Last Dose The last dose prescribed to be administered during the 24 hours of data collection (not necessarily the last dose of a course)

Stat Dose A single dose prescribed to be given as a “one-off”; often at a specific time for example as part of surgical prophylaxis. These may be prescribed in a specific section of a drug chart.

Restricted Antimicrobial

An antimicrobial that is reserved within a given organisation because of its spectrum of activity, resistance patterns or cost; or because only a specific clinical area uses it.

Ward Stock Routinely used antimicrobials that are held as routine stock on a ward and supplied to a ward against a stock list rather than an individual prescription.

6. Results

6.1 Demographics and Overview of Omissions and Delays

Overview of all data

45 acute trusts, four community health & five mental health trusts participated

6062 patients from the 54 trusts were prescribed 21,825 doses of antimicrobials

5.3% (1151/21825) doses were omitted

13.2% (802/6062) patients missed a dose

6.3% (565/8923) last doses were delayed

7.7% (467/6062) patients were overdue an antimicrobial dose at the time of the audit.



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6.1.1 Overview for Acute Trusts 17,470 patients from 45 acute trusts were audited

33.9% (5899) patients were prescribed 21390 doses of 8748 antimicrobials.

The median number of doses prescribed per patient was 3 (range 1 to 7).

56.6% (12106) of doses prescribed were parenteral.

5.2% (1120/21390) of prescribed doses were omitted

Patients missed between 1 and 4 prescribed doses with a median of one.

13.2% (781/5899) patients missed at least one dose ie 1 in 7 patients

The rate of omissions ranged from 0% in one small trust to 9.7%; with 1.4% as the lowest rate in a trust reporting omissions.

Trusts ranged between none and 100% of omitted doses being first doses.

15.2 % (3261/21390) of prescribed doses were first doses

9.6% (313/3261) of prescribed first doses were omitted

27.9% (313/1120) of omitted doses were first doses

10 trusts had no omitted first doses and for one trust all the first doses prescribed were omitted, for the remaining trusts 1.7 to 42.9% of first doses were omitted.

6.4% (562/8748) of last doses were delayed

7.9% (465/5899) of patients (1 in 13) were overdue a dose at the time of the audit

18% (1066/5899) of patients (1 in 6) had at least one omitted and/or delayed dose

6.1.2 Overview for Community Health Trusts

651 patients from four community health trusts were audited

14.7% (97/651) patients were prescribed 265 doses of 109 antimicrobials.

Median number of doses prescribed was 3 (range 1 to 4)

94.5% (250/265) of prescribed doses were enteral.


The median number of omitted doses was one (range 1 to 2)

10.3% (10/97) of patients (1 in 10) missed at least one prescribed dose.

The rate of omissions ranged from 1.7% to 14.3% in trusts.

Only one trust omitted any first doses and these were a quarter of all the doses omitted in that trust.

One prescribed dose was delayed by at least four hours

11.3% (11/97) patients (1 in 9) had at least one prescribed dose omitted or delayed.

6.1.3 Overview of Mental Health Trusts 1534 patients from five mental health trusts were audited

66 (4.3%) were prescribed 170 oral doses of 66 antimicrobials

Median number of doses prescribed was 3 (range 1 to 4)


Median number of omitted doses was 2 (range 1 to 3)

16.7% (11/66) of patients missed at least one dose

The rate of omissions ranged from 0% in one trust to 21.1%; with 2.6% as the lowest rate in a trust reporting omissions.

25 first doses were prescribed and 20% (5/25) of these were omitted

Trusts ranged between 0 and 75% of omitted doses being first doses

Two doses were delayed by at least two hours – these were prescribed for a patient who also missed a dose.



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6.2 Omissions

All omissions were allocated to one of six reasons for omission by the data collectors as described in the audit guidance. The categories were away, blank, not available, no route available, other and refused (see section 4 above for definitions of these terms)

6.2.1 Acute trusts – all omitted doses

In acute trusts 5.2% (1120/21390) of prescribed doses were omitted. The rates of omissions ranged from 0% in one small trust to 9.7% of doses prescribed; with 1.4% as the lowest rate in a trust reporting omissions. The three most frequently reported reasons for omission were; a “blank” administration box on the drug chart (29%), followed by ”other” (26%) and then “not available” (19%). The least frequently cited reason for omission was the patient being “away” from the ward (3%); whilst “no route” available and patient “refusing” the dose were both found to be 12%. See Figure 1. The reasons for omission of all doses and first doses are also described in table 4 on page 10.

Figure 1 Percentage of omitted doses for each reason in acute trusts

Aw ay, 3%

Blank, 29%

Refused, 12%

No route, 12%

Not available, 19%

Other, 26%

Away

Blank

Refused

No route

Not available

Other

6.2.2 Acute Trusts - Omissions by reason More detail is given for each reason for omission in acute trusts starting with the least frequently reported Patient “Away” from ward was the least frequently reported reason for omission affecting 3% (28/1120) of omitted doses in acute trusts. Patients were away from the ward eg having an investigation, visiting the physio etc and missed a dose; that is the dose had not been administered by the time the next dose was due.

“No route” available was recorded as the reason for omission for 12% (134/1120) of omitted doses in acute trusts. This affected patients for whom there was eg no intravenous access or their naso-gastric tube was blocked or had been removed. “Refused” by the patient accounted for 12% (138/1120) of omissions. Refusal to take a dose occurred over all the medically orientated care areas and less frequently in critical care, surgical areas and maternity.



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An “Other” reason was recorded for 26% (291/1120) of doses not administered; these were reasons not covered by the other 5 categories; this could be because a blood level was awaited, the prescribed requested the medicine held or there was no allergy status documented. Many of these omissions could be considered intentional.

Leaving the administration box entirely “blank” was the most frequently reported 29% (320/1120) reason for omitting doses. The nurse leaving the administration box blank implied that the dose had not been given.

In 20.9% (67/320) of occurrences where the administration box had been left blank; data collectors were able to speak to the nurse who confirmed she had given the dose but had forgotten to sign the chart. In 79% of instances the nurse was either not available to have the discussion, could not remember if they had given the dose or confirmed they had not given the dose. Thus it is possible that further doses had been given but not recorded suggesting 20.9% may be an underestimate of the number doses actually given with no documentation.

“Not available” was the reason for omission recorded for 19% (209/1120) of omitted doses. It was possible for data collectors to locate and estimate 30% (63/209) of the antimicrobials were available on the ward at the time the dose had been prescribed to be given; but the nurse for what-ever reason had not been able to find it.

6.2.3 Omissions in acute trusts perceived as being due to the method of supply of the antimicrobials.

Antimicrobials are provided to clinical areas as a stock item where they are likely to be routinely used; whilst agents that are not routinely used in a care area, have a resistance problem, are expensive, or are second or third line treatment are more typically supplied against an individual prescription. A comparison of prescribed doses and omissions of antimicrobials stocked on wards and those supplied against individual prescriptions is shown in Table 1.

Table 1 Acute Trusts - Antimicrobial doses prescribed and omitted by type of supply arrangement

Number (%) of doses kept as ward stock

Number of doses (%) not stocked and supplied as individual

prescriptions

Number of doses prescribed 17712 (82.8%) 3671 (17.3%)

Number of doses omitted 777 343

% of doses omitted 4.4% 9.3% (p<0.001)

Doses supplied on individual prescriptions were found to be omitted twice as often (9.3%) as those routinely available as ward stock (4.4%) (p<0.001). In comparison there was no significant difference in the rates of omission for “restricted” antimicrobials and those available for routine prescribing see Table 2. Table 2 Acute Trusts - Antimicrobial doses prescribed and omitted by availability status

Unrestricted antimicrobials

Restricted antimicrobials

Number of doses prescribed 18100 (84.6%) 3290 (15.4%)

Number of doses omitted 928 192

% of doses omitted 5.1% 5.8% (p<0.1)

6.3 Community Health - Omissions by reason

Twelve doses in total were omitted in the community health setting. 4.5% (12/265) of prescribed doses were omitted. This was a lower omission rate than for acute trusts. In one case (8%) the patient was away from the ward; in three cases (25%) the antimicrobial was recorded on the drug chart as being not available (the data collectors did not report being able to find any of the doses in the care area) and in 8 cases (67%) the administration box on the drug chart had been left blank by the nursing staff. In half of these cases data collectors; were able to confirm with nurse that she had in fact given the dose but had forgotten to record it on the drug chart. Table 3 describes these results.



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6.4. Mental Health - Omissions by reason Nineteen doses in total were omitted in the mental health setting. 11.2% (19/170) of prescribed doses were omitted. In one case there was a recorded “other” reason for non-administration and there were two cases where the patients refused doses. In seven cases the administration box on the drug chart had been left blank; the data collectors were able to confirm in two cases (28.6%) that the nurse had in fact given the dose but had forgotten to sign the chart. For the other five cases the data collectors were either unable to speak to the nurse responsible for administering the dose at the time of data collection or if the nurse was available she confirmed she had not administered the dose. A reason of non-availability was recorded for just under half (9/19) of the omitted doses. The pharmacy staff collecting the data found two of these doses in the clinical area and estimated they would have been available to be administered. Five of the nine doses omitted because of non-availability were first doses of courses. These results are described in Table 3.

Table 3 Community and Mental Health Omissions by reason

Reasons for Omission

Community Health Mental Health

Number of omissions

% of omissions Number of omissions

% of omissions

Blank 8 67 7 36.8 Other 0 0 1 5.5 Not available 3 25 9 47.4 Refused 0 0 2 10.5 No route 0 0 0 0.0 Patient Away 1 8 0 0.0 Total 12 100 19 100.0

Mental Health patients were no more likely to refuse a dose (11%) than physical health patients in an acute setting (12%).

6.5 Acute trusts - omitted first doses In acute trusts 15.2% (3261/21390) of doses prescribed were first doses. Of these 9.6% (313/3261) were omitted. The reasons for omission were of similar proportion to those for all doses (see Table 4) except for the non-availability category which was almost doubled in frequency; from 19% to 33% (p< 0.001). 807 doses were omitted and 17282 doses administered from the “rest of the course”; an omission rate of 4.45%. First doses were found to be omitted twice as frequently as doses from the rest of the course (9.6% v 4.45% p< 0.001). This was a statistically significant difference. Table 4 Acute Trusts - Reasons for omission of all and first doses of antimicrobials

Reason for omission All antimicrobial doses First doses of antimicrobials

Number % Number %

Blank 320 29 77 24.6

Other 291 26 78 25.0

Not available 209 19 103 33.0 (p< 0.001)

Refused 138 12 25 8.0

No route 134 12 26 8.4

Patient Away 28 3 3 1.0

Total 1120 100 312 100.0

Reviewing omission rates of first doses for individual trusts there were ten trusts where no first doses were omitted and in one where all of the first doses prescribed were omitted. For the remaining trusts the percentage of first doses omitted ranged from 1.7 to 42.9%. And considering the proportion of first dose omissions as a percentage of all omissions these covered the complete spectrum from none to 100% of all omitted doses being first doses. The trust with 100% of omitted doses being first doses had a low (1.4%) overall omission rate.



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Further examination of omitted first doses revealed that although four trusts had very low (1.4 to 3.5%) overall rates of omission; significant proportions of these omissions (72 to 80%) in three trusts and in one trust all omissions were first doses. For other trusts their first dose omission rate was more in keeping with their total omission rate.

6.6 Community Health – all and first dose omissions

Twelve of the 265 doses prescribed for 97 community health patients were omitted – a rate of 4.5%. Although small numbers of patients were both audited and prescribed antimicrobials the rate of omission was lower than that for the acute trusts. 9.8 % (26/265) of doses prescribed were first doses and the one (3.8% or 1/26) first dose that was omitted had nothing recorded in the administration box.

6.7 Mental Health – all and first dose omissions 11.2% (19/170) of doses prescribed in mental health trusts were omitted. 14.7% (25/170) of prescribed doses were first doses; 20% (5/25) of these were omitted – all were recorded as not being available. The most common reason for non-administration of all doses was the antimicrobial not being available (49% - 9/19), this was more than double the rate for acute trusts. In 37% (7/19) of cases the administration box had been left blank and on one occasion (5%) another reason was recorded. Two doses (11%) were refused. Refusal of doses was no more common in mental health patients than in physical health patients in an acute setting.

6.8 Enteral and Parenteral doses – all trusts All doses prescribed to be administered in mental trusts and 95.6% (250/265) of those prescribed in community health trusts were enteral. However 56.5% (12085/21390) of the doses prescribed in acute trusts were intended to be administered parenterally. In acute trusts 44% (490/1120) of omitted doses were parenteral and 56% (630/1120) were enteral. Enteral doses were more frequently omitted than parenteral doses and this was statistically significant (p<

0.001).

Table 5 Reasons for omission for enteral and parenteral antimicrobial doses in Acute Trusts

Reason for Omission

Enteral Parenteral Acute All

Number % Number % Number %

Blank 183 29.0 137 28.0 320 29

Other 122 18.6 169 34.5 291 26

Not available 155 24.6 54 11.0 209 19

Refused 117 18.6 21 4.3 138 12

No route 48 7.6 86 17.6 134 12

Patient Away 5 0.8 23 4.7 28 3

Total 630 100.0 490 100 1120 100

In acute trusts enteral doses were found to be more frequently “not available“ than parenteral doses (p<

0.001). But “no route” was more frequently cited as a reason for non-administration of parenterals than enterals (p< 0.001). “Other” was more frequently cited for parenterals (35%) than for enterals (18.6%).

6.9 Results by Care Areas all trusts

Patients in acute and community health trusts were allocated to one of eleven pre-defined care areas by the pharmacy staff collecting the audit data according to the ward the patient was on. No allowance was made for outliers. All the community health patients were classified as rehabilitation/intermediate care, except two care of the elderly patients who received all the doses of antimicrobials prescribed for them. Mental health trust patients were allocated to one of six care areas that were specific to mental health.



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6.9.1 – Acute Trusts Care Area Demographics The numbers of patients prescribed antimicrobials in the different care areas varied widely; with quite small numbers from surgical admissions (68), maternity (70) and intermediate care (71) and over a thousand in both general surgery (1132) and specialist medicine (1517) – which included infectious diseases patients. Details are given in Table 6. Table 6 Demographics of patients and prescribed antimicrobials by acre areas in acute trusts Care Area Number of

patients prescribed antimicrobials

Number of anti-microbials prescribed

Number of antimicrobial doses prescribed

Proportion of doses that were parenteral (%)

Admissions surgical 66 91 218 62.6

Admissions medical 427 589 1497 55.7

Care of the elderly 592 734 1910 39.1 Critical Care 358 626 1406 89.6

General Medicine 712 1005 2523 50.0 General Surgery 1132 1555 4036 64.8

Maternity 70 100 266 36.0 Paediatrics 548 1058 2223 70.9

Intermediate Care 71 84 198 16.7 Specialist Medicine

1 1517 2300 5680 46.3

Specialist Surgery 406 606 1435 55.6 Overall data 5899 8748 21390 56.5

Note 1 covers eg cardiology, gastro, infectious diseases, respiratory patients Intermediate care had the smallest proportion of parenteral doses prescribed (16.7%); followed by maternity at 36%. Critical Care at 89.6% had the highest proportion of parenteral doses prescribed.

6.9.2 Acute Trust Omissions by Care Areas Information on antimicrobial doses prescribed and omitted are described in Table 7. The table is ranked with highest omission rates at the top. The ranking for omissions of first doses remained the same as all doses except for surgical admissions which moved into second place ahead of care of the elderly. Both intermediate care and surgical admissions had relatively small numbers of patients prescribed antimicrobials but high omission rates.

In contrast maternity the other care area with small numbers of patients prescribed antimicrobials had low omission rates of both first and all doses.

Both critical care and paediatrics had large numbers of antimicrobial doses prescribed but low rates of omission.



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Table 7 Acute Trust numbers of antimicrobial doses and first doses prescribed and omitted by care areas Care Area Number of

doses prescribed

Number of doses omitted

% of all doses omitted

Number of first doses prescribed

Number of first doses omitted

% first doses omitted

Intermediate Care 198 17 8.6 29 8 27.6 Care of Elderly 1910 152 8.0 229 34 14.8 Admissions Surgery 218 14 6.4 38 8 21.1 General Surgery 4036 242 6.0 707 76 10.7 Specialist Medicine 5860 332 5.8 745 99 13.3 General Medicine 2523 134 5.3 288 21 7.3 Specialist Surgery 1435 71 4.9 193 13 6.7 Admissions Medicine 1497 62 4.1 387 29 7.5 Critical Care 1406 36 2.6 198 12 6.1 Maternity 266 7 2.6 49 1 2.0 Paediatrics 2223 53 2.4 398 12 3.0 Overall data 21390 1120 5.2 3261 313 9.6

6.9.3 Acute Trust Care Areas Reasons for Omission Table 8 Acute Trusts Reasons for omission by care area as percentages of all doses omitted in the care area

Care Area Away Blank Refused No route Not available

Other Total

Admissions medical 0 32 26 8 8 26 100 Admissions surgical 0 21 0 14 50 14 100 Care of the elderly 0 33 17 10 24 16 100 Critical Care 11 14 3 11 22 39 100 General Medicine 0 25 14 13 14 34 100 General Surgery 2 21 12 14 21 31 100 Intermediate Care 0 29 12 6 35 18 100 Maternity 0 57 0 0 14 29 100 Paediatrics 0 30 6 11 6 47 100 Specialist Medicine

5 32 11 14 18 20 100

Specialist Surgery 4 39 7 4 15 30 100 Overall 3 29 12 12 19 26 100

Patient’s being “away” from the ward was the least frequently reported reason for admission in all care areas except critical care where patient “refusal” was the least frequently reported (would correlate with most critical care patients being sedated). “Refusal” was reported for a quarter of medical admissions omissions. “No route” available appeared not to be more of an issue in any one care area compared to another. Leaving the administration box “blank” was the most frequent reason for omission for five of the care areas (admissions medical, care of the elderly, maternity, specialist medicine and specialist surgery). But was less of an issue for critical care areas.

For four care areas “other” was the most frequently reported reason for omission and for two areas intermediate care and surgical admissions “not available” was the most frequently reported reason with admissions surgical areas reporting 50% of doses omitted for this reason.

6.9.4 Acute Trust “Stat” dose prescribing Single doses to be administered eg as part of surgical prophylaxis are often prescribed as “stat” doses; trusts may have a specific section of the drug chart to accommodate this. First doses of a course of treatment can also be prescribed as “stat” doses and indeed are advocated in some trusts. A single dose for treatment or prophylaxis was also considered as a first dose for this audit.



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3261 first doses prescribed

9.5% (313/3261) first doses omitted

21.3 % (695/3261) of first doses were prescribed as stat doses

5.2% (36/695) of stat doses were omitted

2566 first doses were prescribed as regular medication

10.9% (279/2566) of first doses prescribed on the regular side of drug chart were omitted.

Table 9 Acute trusts - Administration of first doses prescribed as “stat” or as regular medication

Prescribed as “stat” Prescribed as regular medication

Administered 695 (95.1%) 2566 (89.1%) Not administered 36 (5.2%) 279 (10.9%) p< 0.001

The first dose of a course of antimicrobials were omitted twice as frequently when prescribed on the regular side of the drug chart compared to the “stat” section of a drug chart. This was a statistically significant difference. (p<0.001)

A detailed table of omissions of first doses, “stat” doses and first doses prescribed as stat doses by acute trust care areas is in Appendix C.

6.10 Omissions by care area for Community and Mental Health patients

All but two of the community health patients were from the rehabilitation /intermediate care area and all twelve omissions related to this care area. The two care of the elderly patients received all of the prescribed doses of antimicrobials. 4.5% (12/265) of all antimicrobials doses were omitted and 3.8% (1/26) of first doses were omitted.

For mental health patients no data was recorded for Child and Adolescent nor for Eating Disorder patients. No doses were omitted in Learning Difficulties and only two (and no first doses) in Secure and Forensic Health patients. Details of the omissions for the four mental health care areas where omissions occurred are described in Table 10. The table is ranked with the highest omission rate at the top. Table 10 Mental Health All and First dose omissions of antimicrobials by care areas

Care Area Number of doses prescribed

Number of doses omitted

% doses omitted

Number of first doses prescribed

Number of first doses omitted

% first doses omitted

Working Age Mental Health

45 9 20.0 7 3 42.9

Older Peoples Mental Health

81 8 9.9 14 2 14.3

Secure & Forensic Health

38 2 5.3 3 0 0.0

Learning Disabilities

6 0 0.0 1 0 0.0

Overall 170 19 11.2 25 5 20.0

6.11 Results for delayed last doses The last dose prescribed to be given was assessed by the data collectors as to whether it had been given or if was overdue in which case it was considered delayed. The delay at the time of the audit was measured in hours (underestimating the duration of the delay but identifying the number of doses that had been delayed)



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6.11.1 Delays - Acute Trusts

8748 last doses were prescribed

6.4% (562/8748) were recorded as delayed

28% (157/562) of delayed doses were delayed by up to 1 hour at the time of the audit.

54% (302/562) of delayed doses were delayed by up to 2 hours at the time of the audit

80% (454/562) of delayed doses were delayed by up to 4 hours at the time of the audit

7.9% (465/5899) of patients (1 in 13) experienced a delayed dose

Figure 2 Acute Trusts delayed antimicrobial doses by length of delay at time of audit

A first dose prescribed to be given could also be the last dose due to be given during the audit period. 42% (236/562) of the delayed doses were first doses. 7.2% (236/3261) of first doses were delayed. First dose delays followed a similar pattern of length of delay to that seen with all dose delays.

6.11.2 Acute Trust Delayed Parenteral and Enteral antimicrobial doses There was no statistically significant difference in the frequency of delays between enteral and parenteral doses. Table 11 Acute Trusts – delayed parenteral and enteral antimicrobial doses

Parenteral antimicrobials doses

Enteral antimicrobial doses

Number of doses prescribed 12107 9283 Number of doses delayed 311 251 % of doses delayed 2.56% 2.7%

6.11.3 Acute Trust Delays by Care Area All care areas experienced delayed last doses, maternity and paediatrics had higher proportions of delays compared to other care areas; although both of these care areas had low omission rates compared to other care areas. Table 12 ranks the care areas by percentage of last doses delayed.



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Table 12 Acute Trusts – delayed doses by care areas

Care Area Number of last

doses prescribed

Number of delayed last doses

% of last doses delayed

% patients who had a delayed dose

Paediatrics 1058 125 11.8 22.8

Maternity 100 11 11.0 15.7

Care of the elderly 734 68 9.3 11.5

Intermediate Care 84 6 7.1 8.5

Admission surgical 91 6 6.6 9.1

General Medicine 1005 57 5.7 8.0

Specialist Medicine

2300 125 5.4 8.2

General Surgery 1555 84 5.4 7.4

Admission medical 589 29 4.9 6.8

Specialist Surgery 606 26 4.3 6.4

Critical Care 626 25 4.0 7.0 Overall data 8748 562 6.4 9.5

6.11.4 Delayed Doses Community and Mental Health Patients Only one Community Health dose was delayed; which was by at least four hours and this was a rehabilitation/intermediate care patient. There were two Mental Health doses delayed by at least two hours; these were in Older People’s Mental Health.

6.12 Electronic prescribing sites compared to traditional prescribing As electronic prescribing is thought to bring benefits to patients a sub-analysis of electronic prescribing versus traditional prescribing sites was performed to see if electronic prescribing reduced the number of omissions and delay. The omission rate for both types of prescribing was exactly the same (5.2%) However the omission rate for electronic prescribing sites was lower for first doses (8.7%) compared to traditional prescribing sites (9.7%) however this difference was not statistically significant. A greater proportion of first doses are prescribed as “stat” in electronic prescribing sites compared to traditional prescribing (32.1% v 20.4%). And changing the route eg from parenteral to oral creates a new prescription in electronic prescribing systems whilst for many trusts multiple routes of administration would count as one prescription when prescribed on paper. Table 13 Acute Trusts – Antimicrobial dose omission by electronic and traditional prescribing sites

% of antimicrobial doses administered

% of antimicrobial doses omitted

Electronic Prescribing sites 1805/1904 (94.8%) 99/1904 (5.2%)

Traditional Prescribing sites 18465/19486 (94.8%) 1021/19486 (5.2%)

All doses 20270/21390 (94.8%) 1120/21390 (5.2%)

The reasons for omission were similar between electronic prescribing and traditional prescribing sites; see Table 14. Despite having an electronic prescribing system 19% of administration records were left blank.



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Table 14 Acute Trusts – Comparison of reasons for omission for electronic and traditional prescribing sites

Reasons for Omission Omitted antimicrobial doses

Electronic Prescribing Sites Traditional Prescribing sites

Number % Number %

Blank 19 19.2 301 29.5 Other 34 34.3 257 25.2 Not available 15 15.2 194 19.0 Refused 13 13.1 125 12.2 No route 17 17.2 117 11.5 Patient Away 1 1.0 27 2.6 Total 99 100.0 1021 100.0

A larger proportion of doses were reported as delays by trusts using electronic prescribing (16% 133/831) than traditional prescribing 5.4% (429/7919). This difference was statistically significant (p< 0.001). 1 in 3.6 patients from electronic prescribing sites experienced a delayed dose whilst for traditional prescribing sites the number reported was 1 in 12. Table 15 Acute Trusts – comparison of delayed last doses for electronic and traditional prescribing sites

Electronic Prescribing Sites Traditional Prescribing Sites

Number % Number %

Last doses prescribed 831 7919

Delayed Last doses 133 16% 429 5.4%

Number of patients prescribed antimicrobials

1224 5419

No of patients with a delayed dose

339 27.7% 428 7.9%

7. Discussion

Was it appropriate to focus on antimicrobials rather than all medicines? The NPSA recommended trusts should have a list of medicines where delays or omissions were considered to be critical; they also advised that antimicrobials (along with anti-coagulants, insulin, resuscitation medicines and medicines for Parkinson’s Disease) were included on the list. Antimicrobials are used by all care areas in all types of trust which allowed a wide range of organisations to participate. Antimicrobials are frequently prescribed agents and all health care staff should have an awareness of the importance of administering antimicrobials; suggesting that performance with antimicrobials is likely to reflect similar performance with other medicines. Focusing on antimicrobials made the data set more manageable.

What were the most frequently reported reasons for omission in acute trusts? Leaving the administration box blank was the most frequently reported reason for omission (29% of cases of missed doses). Where possible Pharmacy Staff followed up whether the nurse had given the dose but had forgotten to sign the chart. For 20.9% of the blank administration boxes it was possible to confirm with the nurse this was the case. The data may have been skewed by the way the information was obtained and the pharmacy staff were not always able to complete the task. However this was such a large proportion of the missed doses that work needs to be undertaken locally with nursing staff to improve record keeping (Standard 8 point 2.10 of the Nursing and Midwifery Council’s Standards for Medicines Management

2

states ‘……you must make a clear accurate and immediate record of all medicines administered, intentionally withheld or refused by the patient ensuring the signature is clear and legible ….. In addition ….. where medication is not given the reason for not doing so must be recorded…..). Raising the awareness of the importance of patient’s receiving their medication on time is also key.



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The second most frequently reported reason for omission was “Other” at 26% – these were omissions where a recorded reason for omission had been made but it was not covered by one of the remaining five reasons. “Other” could include waiting for a level; withheld on prescriber’s instructions, unable to read the prescription etc. Some of these omissions could be considered intentional and therefore justified – but more local investigation is required and solutions implemented to reduce the risk to patients. 19% of omitted doses were recorded as “Not available”. Where this was the case auditors searched for the dose on the ward to see if it had been available at the time the dose was due. In 30% of cases the dose was assessed as being available for administration. This figure may be an under-estimate because the search for all “non-available” doses may not have been completed. Further analysis of the “not availables” was undertaken to see if the method of supply affected the omission rates; and these results are discussed later. Overall 12% of omitted doses were due to patient’s refusing doses. The proportion of doses missed for this reason was higher in care of the elderly and in medical admissions. Clear explanations to patients about new treatments started may help adherence. The same percentage of omitted doses was due to the route of administration not being available to use, this would include no intravenous access or no nasogastric (ng) tube in place. Prescribers need to be aware of routes available at the time of prescribing and where necessary plan ahead if a route this likely to become unavailable eg poor veneous access or confused patient’s removing ng tubes. Nursing staff must liaise promptly and medical staff must respond promptly to such situations. Patients being Away from the ward provided the smallest percentage (3%) of omitted doses. However Trusts must have clear processes for “catching up” with doses omitted or delayed.

Are first doses omitted more than other doses? First doses were found to be omitted more often than other doses. In acute trusts patients were found to miss first doses twice as often as other doses and this was the case across all care areas. This was an important finding because first doses of antimicrobial courses may be critical (eg in sepsis). This was a particular issue for surgical admissions where timely administration of antimicrobial prophylaxis and therapy is vital. A smaller proportion of first doses were audited in community health and mental health settings it is therefore more difficult to draw conclusions. The audit showed acute trust patients were twice as likely to miss a first dose because it was not available (33%) compared to all doses (19%) and this was a statistically significant finding. Should the first dose of a course of treatment be prescribed as a stat dose? The audit suggests prescribing first doses as stat does reduce the omission of doses. First doses were omitted twice as frequently when prescribed on the regular side of the drug chart (10.9% - 279/2566) compared to prescribing as a stat dose (5.2% - 36/695). The omission rate of first doses in Electronic Prescribing sites was lower than traditional prescribing sites (8.7% v 9.7%) but was not statistically significantly different. However a greater proportion of first doses are prescribed as stat in electronic prescribing sites (32.4% v 20.4%) and these tend to be omitted less frequently than first doses prescribed as part of a regular prescription. Some trusts have a policy that first doses of courses of treatment should be prescribed as a stat dose; as the omission rate was lower than for first doses prescribed on the regular part of the drug chart the audit results suggest all trusts should adopt such a policy. A review of local policies where they do exist is also recommended as anecdotally it would appear that although such a policy may exist it is not always adhered to.

Are doses omitted more often from some care areas than others? Omission rates varied in care areas from 2.4% in paediatrics to 8.6% in intermediate care. Omission frequencies were highest in intermediate care, care of the elderly and surgical admission care areas in acute trusts (although the small numbers of intermediate care patients make the findings in this care area less reliable). Local actions on omitted doses should be prioritised to the areas that have particular issues for individual trusts.



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A smaller proportion of community health care area patients (14.7%) were prescribed antimicrobials but doses were missed less frequently (4.5%) compared to acute care settings (5.2%). There is however a problem to be addressed. An even smaller proportion of patients in mental health settings (4.3%) were prescribed antimicrobials but these patients missed doses more frequently than those in acute care settings (11.2% of doses omitted compared to 5.2%) and more often because the dose was not available (49% v 19%). Mental Health Trusts are encouraged to review supply processes locally. Does being on a stock list improve the likelihood of a dose being given? Patients were found to miss twice as many doses if the antimicrobial was supplied against an individual prescription compared to those available in the clinical area as stock. This was statistically significant. Locally trusts must review supply processes – including access to anti-microbials out of hours. And stock lists must be reviewed regularly. Traditional methods of controlling access to antimicrobials (ie requesting an individual prescription to dispense against) appear to lead to more missed doses. Concerns about resistance developing could be reduced by adopting the Department of Health’s approach of Start Smart then Focus

3 where prompt effective anti-microbial treatment is initiated against

local guidelines within an hour of diagnosis then a Focus is made by reviewing by 48 hours to Stop, Switch, Change Continue or OPAT (outpatient parenteral antibiotic therapy)

Are restricted antimicrobials missed more often than freely available agents? No there was no statistically significant difference between omissions of restricted antimicrobials and those freely available; unlike those that are not stocked onwards. Were delayed doses less of a problem than omitted doses? Unfortunately not – there were fewer last doses prescribed (8923) however a greater proportion of these were delayed (6.3% - 565/8923) compared to doses being omitted (5.3% - 1151/21825). The audit identified the number of doses that were delayed but the length of the delays was an under-estimate as the duration of the delay was measured at the time of data collection rather than up to when the dose was eventually given (a number of these delays would go on to become omissions if the delay lasted until the next prescribed dose was due). The audit did not identify the number of patients whose dose was delayed because they were away from the ward – so it was not possible to contrast those patients missing a dose and those catching up with dose when they returned to the ward later What can be done to reduce delays? Similar actions as those needed to reduce omissions will help reduce the number of delays; including raising awareness to ensure doses are given on time; particularly for first doses. A higher proportion of first doses were delayed (7.2% - 236/3261) compared to all doses (6.3% - 565/8923). Providing guidance on what do to about doses that get out of synch with their prescribed times may be helpful. Was patients being “away” from the ward an issue for delays and omissions? Patients being away from the ward accounted for a relatively small percentage of omissions (3%). Reasons for delayed doses were not recorded but could include being away from the ward. The delayed dose data was not sensitive enough to identify if patients being away from the ward caught up with doses later and therefore did not turn into an omission.

Are parenteral doses delayed or omitted more often than enteral ones? Although the overall data showed there was no difference in delays of parenteral and enteral doses; a closer look at local data would be helpful in trusts where the practice is to give enteral medication first and then give the parenteral doses. Enteral doses were more frequently omitted than parenteral ones this could be because more importance is given to parenteral than enteral doses because the route of administration implies the patient is sicker.



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Does electronic prescribing reduce the frequency of omissions and/or delays? No difference was found in the omission rates for electronic prescribing and traditional prescribing sites. There were slightly fewer first dose delays in electronic prescribing sites. Electronic prescribing sites like traditional prescribing sites had a significant proportion of omissions where the administration box was left blank. There was however a higher proportion of delays reported for electronic prescribing sites, this data would have been easier and more accurate to collect and may be a more true representation of delays. Was the methodology robust? Point prevalence data collection is a well recognised methodology and is already in place in many trusts for collecting antimicrobial prescribing data. The data collection forms and spread sheets can be used per se or adapted for use by organisations to repeat delayed and omitted dose audits; there are examples of this happening. What were the limitations of the audit? A large number of people collected the data from clinical areas and then a smaller number of people entered data onto the trust’s spread sheets. It was assumed data had been collected and entered as intended. Despite detailed guidance being given; there could have been local interpretation and there was a need to cleanse the data submitted and ensure all the relevant boxes had an entry. The number of omissions and delays could be an under-estimate of the true picture as data was not collected on Mondays to mitigate against different supply mechanisms at the weekend. The study design allowed for an accurate record of the number of doses delayed to be measured but it was not possible to measure the exact duration of the delays as the data was collected at a specific point in time. Different methodology (such as an observational study) would need to be used to measure the delays accurately. However, it is generally recommended that first doses should be administered within an hour of the prescribed time and other doses within two 2 hours. This audit was sensitive enough to show that there is an issue with delayed doses. Trusts decided whether to audit all occupied beds or to target care areas; this may have skewed data particularly for those care areas with small numbers. The audit did not distinguish between doses prescribed for treatment or for prophylaxis. For electronic prescribing sites the number of “courses” of treatment given may appear high as stat doses and change of route prescribing is recorded as a separate prescription.

8. Summary

Omitted and Delayed doses were found to be affecting 13.2% and 7.7% of the patients audited who had been prescribed antimicrobial agents during a 24 hour period in December 2010. In acute trusts 5.2% of prescribed doses were omitted; the commonest reason was because nothing was documented in the administration box (29%); non-availability of the dose was recorded in 19% of cases; no route and refusal were both 12% and away from the ward just 3%. In 26% of cases the omission was due to a reason not covered by the other categories. First doses of a course; first doses not prescribed as stat and antimicrobials not stocked on the ward were twice as likely to be missed. 19% of doses reported as not available were found on the ward and would have been available to administer. On follow up at least 29% of doses not signed as being administered had been given. There were differences in omission rates for different care areas in acute trusts; care of the elderly patients had a high omission rate and critical care and paediatrics a low omission rate. Electronic prescribing sites had the same omission rate as traditional prescribing sites. Mental Health and Community Health patients were prescribed fewer antimicrobials compared to acute trusts. 16.7% of mental health patients missed at least one dose more often through non-availability than in acute trusts.



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The issues influencing delayed and omitted antimicrobial doses are multi-factorial, complex and require multi-disciplinary solutions.

9. References

1. National Patient Safety Agency Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital. February 2010.

2. Nursing and Midwifery Council Standards for Medicines Management. NMC 2007 3. Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated

Infection (ARHAI) - Antimicrobial Stewardship: “Start Smart - then Focus”. Department of Health London 2011.

10. Acknowledgements

Many thanks are offered to Pharmacy Staff who collected the data Local audit co-ordinators for ensuring consistency of data collection and data entry Karen Colls for her Excel expertise Christine Masterson for excellent administrative support



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Appendix A. Participating Trusts

Ashford & St Peter’s Hospitals NHS Trust

Basildon & Thurrock University Hospitals NHS Foundation Trust

Basingstoke and North Hampshire NHS Foundation Trust

Bedford Hospital NHS Trust

Berkshire Healthcare NHS Foundation Trust

Buckinghamshire Hospitals NHS Trust

Central London Community Healthcare

Chelsea and Westminster Hospital NHS Trust

Colchester Hospital University NHS Foundation Trust

Croydon University Hospital Trust

Dartford and Gravesham NHS Trust – Admissions

Ealing Hospital NHS Trust

East & North Hertfordshire NHS Trust

East Kent Hospitals University NHS Foundation Trust

East London NHS Foundation Trust

East Sussex Community Health Services

East Sussex NHS Trust

Frimley Park Hospital NHS Foundation Trust

Great Ormond Street Hospital for Children

Heatherwood and Wexham Park Hospitals NHS Foundation Trust

Hillingdon Hospital NHS Trust

Hinchingbrooke NHS Trust

Imperial College Healthcare NHS Trust

James Paget University Hospitals NHS Foundation Trust

Kingston Hospital NHS Trust

Luton and Dunstable Hospital NHS Foundation Trust

Medway NHS Foundation Trust

Mid Essex Hospital Services NHS Trust

Milton Keynes NHS Foundation Trust

NHS Isle of Wight

Norfolk & Norwich NHS Trust

Norfolk Community Health and Care NHS Trust

Nuffield Orthopaedic Centre NHS Trust

Oxford Radcliffe Hospitals NHS Trust

Oxfordshire and Buckinghamshire Mental Health Partnership NHS Trust

Papworth Hospital NHS Foundation Trust

Princess Alexandra Hospital NHS Trust

Queen Victoria NHS Foundation Trust

Royal Brompton and Harefield NHS Foundation Trust

Royal Marsden NHS Foundation Trust

Royal Surrey County Hospital NHS Trust

South Essex Partnership University NHS Foundation Trust

Southend University Hospital NHS Foundation Trust

St Georges Healthcare NHS Trust

Suffolk Mental Health Partnership NHS Trust

Surrey and Sussex Healthcare NHS Trust

Sussex Community NHS Trust

Sussex Partnership NHS Foundation trust

University College London Hospitals NHS Foundation Trust

West Hertfordshire Hospitals NHS Trust

West Middlesex University Hospital NHS Trust

Western Sussex Hospitals Trust

Whipps Cross University Hospital NHS Trust

Winchester & Eastleigh Hospitals NHS Trust



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Appendix B

Guidance Notes on How to complete Data Collection Form Omitted and Delayed Antimicrobials Collaborative Audit

Please read before starting your data collection

On the day of the audit – review all the antimicrobial doses prescribed to be given in the preceding 24 hours. Complete one line for each patient with a current antimicrobial prescription (definitions below), even if there are no omissions or delays. For one omitted or delayed dose complete all details on that line. If more than one omitted dose use the line below to record reasons etc – bracket the two lines together. Where questions are not applicable record a dash

Question Guidance to complete

Bed number This is just to help you know which patients you have collected data for it won’t be used in the analysis – you can use another system – ensuring patient confidentiality

Antimicrobial Name of the antimicrobial – see below for definition

Route Record parenteral & enteral routes. Note we are not auditing topical routes or nebs

On Ward Stock List? Answer yes if the antimicrobial is on the ward stock list – it does not mean that it was actually available on the ward

Restricted Answer yes if the antimicrobial is restricted in your organisation eg it requires micro approval or pharmacy check that it meets indication before it is issued

Rxed doses in 24 hrs Count the doses prescribed to be given over the preceding 24 hours.

First Dose Info (Rxed and stat and omitted)

Covers first doses of courses prescribed to be administered during the 24 hour audit period. Answer yes if the first dose is included in the audit; No if it was given prior to the audit. Then answer yes if it was prescribed as a stat dose with the rest of course on regular section of the drug chart or (N) if entire course is prescribed on the regular section of the drug chart and finally if this dose was omitted – answer yes and continue with the omission reasons on the same line of the data collection form. If the answer is no enter the omission details of any further omitted doses on the rest of the line.

Number of Omitted Doses

Record the number of doses of the antimicrobial that been omitted during the 24 hour audit period – see below for definition. The total includes any omitted first doses. But does not include any delayed doses. If the last dose prescribed to be administered during the 24 hour audit period has not been - given record this as a delay at the end of the row.

Reason omitted Do not use your local omission codes as everywhere has different ones! See below for full descriptions – shortened codes are on the bottom of the data collection form. Include “blanks” this is where there is nothing written in the administration box for a dose; but the next prescribed dose has been given. Where there is a “blank” for the last dose in the audit to be given record this as a delay.

Not available – was it found

For those omissions where the antimicrobial was not available on the care area; attempt to validate if it was actually available. Record yes if the antimicrobial was found on the ward or was available in an Emergency Drug Cupboard out of hours.

Blank – was it given and nurse forgot to sign?

For doses where there is nothing recorded in the administration box can you confirm if the dose was actually given but nurse but they forgot to sign, if so record Yes. Where unable to validate record N. If this relates to the last dose to be given in the audit record as a delay.

Last dose delayed Record yes if the administration box for the last dose prescribed to be given during the audit is blank – signifying the dose has been delayed.

Delayed dose – how long For (hrs)

Where the last dose prescribed for administration during the audit has not been given record the number of hours (to the nearest whole number) between the prescribed time and the data collection time. Not expecting you to be able to identify delays for doses administered earlier as times of administration are rarely recorded.

Don’t forget to complete your name (in case of queries, ward name and date and time of audit. Record the number of patients on the ward, the number with a current antimicrobial prescription and

the total number of antimicrobial courses currently prescribed.



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Guidance Notes on How to complete Data Collection Form Omitted and Delayed Antimicrobials Collaborative Audit

Definitions for the purposes of the collaborative audit

Antimicrobial Any agent that appears in Chapter 5 of the BNF that is given systemically ie topical applications and nebules are excluded but all parenteral and enteral routes are included

Audit The data for the audit can be carried out on any day (reviewing prescriptions for the preceding 24 hours) between Tues 23rd and Fri 26th Nov or Tues 30th Nov and Fri 3rd Dec.

24 hour Audit period The 24 hours preceding the start of the data collection ie if data collection starts at 4pm on Wed 24th, review prescriptions back to 4pm on Tues 23rd.

Blank The administration box has been left entirely blank

Course A course of treatment eg 5 days of oral amoxicillin

Current Prescription Antimicrobial prescription that is valid for administration of doses during the 24 hour audit period

Delayed dose Doses not administered at the time specified by the prescriber. There can be different degrees of delay.

Enteral Antimicrobials given for systemic infections by the oral, nasogastric, PEG or other “tubes” Exclude Nystatin liquid.

First dose The first dose to be given as part of the course of treatment.

Omitted Dose/Omission Doses not administered by the time the next dose is due to be given.

Parenteral Antimicrobials given by injectable routes eg intravenous, intramuscular

Stat/Stat Dose Doses prescribed as one-offs usually on a specific section of the drug chart – sometimes the first dose a course is prescribed as a stat dose and the rest of the course on the regular section of the drug chart

Omission Code Definitions

Code Covers

Away Patient Away from the ward

Refused Patient refuses No route The prescribed route is not available for a variety of reasons

Eg Patient Nil by mouth, vomiting Not cannulated Cannula tissued Fasting Unable to take

Not avail Antimicrobial not available on the ward to be given at that time

Other with reason Things not covered by the above but there is a documented reason to eg with-held on prescribers instructions, awaiting a result back

Blank No signature in the administration box


A collaborative audit of omitted and delayed anti-microbial doses – v 1.1 May2015 (JH/JN)

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Appendix B Data Collection Form

Omitted and Delayed Antimicrobials Collaborative Audit - Individual Antimicrobial Data Collection Form A Please Read accompanying guidance before completing

Name of auditor Ward Date of audit No of pts seen No of pts current antimicrobial Rx Total no of anti-microbial courses prescribed

Bed Antimicrobial Route On

ward Stock

list (Y/N)

Restrict- ed? (Y/N)

Rx’d doses in 24 hr

First dose info Number omitted doses (If more

than 1 complete more lines –

bracket together )

Reason omitted? See below

‘Not available’ was it found? (Y/N)

‘Blank’ Was it given & nurse forgot to

sign (Y/N)

Last dose delayed (Y/N)

Last dose delayed For hrs (Nearest whole no)

Rxed Rxed stat

(Y/N)

Omitted

(Y/N)

Eg1 Tazocin IV N Y 3 Y N Y 2 } Not avail Y - N -

- } Blank - N - -

Eg 2 Gent IV Y N 1 Y Y N - - - - Y 4


A collaborative audit of omitted and delayed anti-microbial doses – v 1.1 May2015 (JH/JN)

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Appendix C First dose prescribed as “Stat” or on the regular side of the drug chart and omissions by care area

Care Area Number of first doses prescribed

Number of Stat doses prescribed

% of first doses prescribed as stat

Number of stat doses omitted

% of first doses prescribed as stat omitted

Number of first doses prescribed on regular side

% of first doses prescribed on regular side

No of first doses prescribed on regular side omitted

% of first doses prescribed on regular side omitted

Admission surgical 38 6 15.8 0 0 32 84.2 8 25.0 Admission medical 387 81 20.9 6 7.4 306 79.1 23 7.5 Care of the elderly 229 39 17.0 1 2.6 190 83.0 33 17.4 Critical Care 198 50 24.7 0 0 149 75.3 12 8.1 General Medicine 288 57 19.8 3 5.3 231 80.2 18 7.8 General Surgery 707 206 29.1 13 6.3 501 71.9 63 12.6 Maternity 49 7 14.3 0 0 42 85.7 1 2.4 Paediatrics 398 89 22.4 0 0 309 77.6 12 3.9 Intermediate Care 29 1 3.4 0 0 28 96.6 8 28.6 Specialist Medicine

745 126 16.8 13 10.4 620 83.2 86 13.9

Specialist Surgery 193 35 18.1 0 0 158 81.9 13 8.2 Overall data 3261 695 21.3 36 5.2 2566 88.7 277 10.8

omitted and delayed medicines - sps.nhs.uk · omitted and delayed medicines in hospital (rrr009) in...

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