Most people in Providence County would likely associate errors involving a patient’s medication to instances where he or she was either given an incorrect dosage of a prescribed medication or administered the wrong medication altogether. While such errors certainly rank among the more common types of medication errors, another less-apparent yet potentially as damaging a mistake is a medication omission. The American Society of Health-System Pharmacists defines an omission error as “the failure to administer an ordered dose to a patient before the next scheduled dose, if any.”
Medications prescribed to attack infectious agents or assist with a course of treatment may be vital in producing positive patient outcomes. Thus, the omission of a medication could very well be just as serious as too much of it being given. One may wonder how it can be possible for a clinician to overlook the administration of medication (particularly those administered intravenously) given the many delivery methods and protocols in place to account for them. A study undertaken by the Pennsylvania Patient Safety Authority revealed the following to be among the most common reasons why IV medications were never given:
- IV medications not sent with patient during transfer, or not being connected, hung, or started upon his or her arrival in a new unit.
- IV pumps or drug delivery systems never being activated.
- IV lines becoming occluded or being mistakenly clamped.
- IV’s being accidentally discontinued or stopped.
- Empty or defective IV bags not being replaced.
- Nurses becoming distracted.
To prevent omission errors, the ASHP strongly recommends nurses stick to scheduled administration times and document any refusals by a patient to take a prescribed medication or any medication availability issues. A lack of such documentation in a patient’s medical record could be seen as evidence a required medication was never given.