Drug Omission — When You Didn’t Get That Important Medication in the Hospital

February 2, 2015

Omission errors are when either  a hospital physician fails to order a vital medication that a patient is on at home, a nurse fails to administer a drug as prescribed, or a pharmacist fails to dispense a prescription. Omission or delay in giving an important medication can have severe or fatal results, for example in pulmonary embolus, or in chronic conditions, delays or omissions can lead to serious harm – for example, delay affects symptom control in Parkinson’s disease.

Over 2,700 medication errors categorized as drug omissions involving more than 500 different medications were reported to the Pennsylvania Patient Safety Authority from January 1, 2013, through April 30, 2013. Antibiotics (19.7%) and medications used for respiratory therapy (11.5%) were the most common omitted medications. More than 21% of reports involved at least one high-alert medication. Most administration omissions involved a medication intended to be given by an intravenous (IV) route (32.9%) or by other injectable routes (38.0%). The most commonly cited types of omissions involving an IV high-alert medication included IV infusions that were not started, IV tubing that was not connected or was clamped, and IV infusion pumps that were not turned on or were turned off.

Drug omissions can occur during any stage of the medication-use process. Medications may be omitted from initial medication lists obtained upon admission, prescribers may omit a drug when writing or entering orders, orders for medications may not be transcribed onto a paper medication administration record, pharmacy personnel may fail to enter an order into the pharmacy computer system or may not deliver medications to patient care areas on time, or nurses may fail to administer the medication as prescribed.

Examples of reports of drug omissions from actual hospital incident reports:

  • Transferred as an emergency from floor to the cath lab for coronary angiography with or without PCI. A large thrombus in the left main stem was noted; at the same time it was noted that intravenous or intra-arterial heparin (a vital anti-coagulant) had not been given. Cardiac arrest team was called resuscitation not successful and patient died.
  • Patient admitted with infected ulcer and cellulitis. At 3 PM the doctor instructed the nurse to give intravenous antibiotics immediately. The doctor returned at 4:30 PM– observations not done and antibiotics not given. Patient was drowsy…. Patient had to go to intensive care unit, where she died from severe sepsis.
  • Diagnosed with pulmonary embolus. Stat dose of enoxaparin (Clexane) prescribed but does not appear to have been given. Patient arrested and died.

Omission of medications, especially, “high-alert medications” is an actual problem that hospitals research and try to deal with every day. The top 10 medications involved in drug omission events reported to the Pennsylvania Safety Authority from January 1, 2013  to April 30, 2013 (there were actually almost three thousand errors voluntarily reported to the Safety Authority)involved 4 high-alert medications: