Reducing harm from missed or omitted and delayed medicines in hospital. Tools to support local implementation

· UK Medicines Information

Hospitals are directed to identify a list of critical medicines where timeliness of administration is crucial.  These tools are designed to support this work.

This main document, originally produced in support of the NPSA alert, has been updated to include new medicine groups and also specific clinical circumstances.

The risks of delay or omission for each drug or drug class are categorised using a traffic light system which aims to help organisations identify the need for specific local action in terms of patient care and incident reporting.

As part of the review process, a new document has been prepared that lists ten treatments and conditions where missing a single dose can be fatal or catastrophic.  This list includes examples of reports submitted to the National Reporting and Learning System.

This list is put forward as a starting point for the production of local lists of very high priority medicines and related conditions that carry very significant risks of death or severe patient harm if a single dose is omitted and delayed.  The list is not universally applicable or totally comprehensive; other medicines such as those for Parkinsons Disease, anticoagulants etc will be considered locally and may be included in local lists.

A collection of good practice guidance from the SPS Medicine Use and Safety Team is also available to support the implmention of this work  (click on link below)



Acute CareAdherenceMedicines SafetyPolicy, Guidance, and StandardsSystem Safety