Back to accessibility links

Reducing the Incidence of Omitted Medication Administration

Project Added:
10 October 2016
Last updated:
24 October 2016

Reducing the Incidence of Omitted Medication Administration at Dubbo Health Service


This project improved education and workflow processes around medication administration, to reduce instances where patients either don’t receive their medication or don’t have a documented reason as to why their medication was not administered.


To ensure that within six months, 100% of patients in the general ward of Dubbo Health Service have documentation stating they have received their medications or have clear documented reasons for omitted doses.


  • Improves patient safety, by ensuring patients receive their medications as charted.
  • Provides clear, documented reasons for omitted dose administration.
  • Reduces harm or potential harm to patients.
  • Reduce the incidences of missed doses reported.
  • Provides clear policies and guidelines around medication supply and administration.
  • Ensures medication safety is included in patient rounding.
  • Delivers regular nurse education on wards.
  • Provides pharmacy with increased involvement in new nurses’ orientation.
  • Provides pharmacy with increased involvement in new medical officers’ orientation.


An omitted dose is a dose that is not administered before the next scheduled dose1. Omission of medication doses occur for variety of reasons and has been reported in publications as a common occurrence. The UK National Patient Safety Agency has reported that up to 20% of medication errors were omitted doses2. Australian studies show an omission rate of up to 11%, with 86% of omitted medications placing patients at some risk of harm1.

Although the majority of incidences are insignificant, it is important to recognise that harm can arise from omitted or delayed medication administration, especially with critical medications. Omitted doses of critical medications may increase hospital length of stay and associated costs to the health service.

A basic preliminary audit, combined with anecdotal reports from clinical pharmacists and Incident Information Management System (IIMS) reports, showed that Dubbo Health Service had a similar issue to the rest of Australia and the UK, with omitted doses and no clear documented reason for dose omissions.


  • Weekly in-service education sessions were delivered by pharmacists to nursing staff over a four-week period, with a one-off presentation to new medical staff in the general ward of Dubbo Health Service. These education sessions covered the following topics:
    • administration and prescribing of critical medications
    • clear prescribing
    • communication regarding new medications, ‘Once Only’ doses and other information during and after rounds.
  • A flowchart was developed and implemented, to provide a clear process for supplying medications.
  • A new process was developed and implemented for nursing staff, ensuring that medication charts were included in the handover process.
  • Omitted doses were included in medication safety discussions during patient rounds.
  • Visual prompts were added on the ward for nurses, with email prompts for Junior Medical Officers (JMOs). Examples of prompts include:
    • Don’t forget to sign the Med Chart when medications are administered.
    • Have you checked with Pharmacy?
    • Charted a STAT dose? Have you informed the nurse looking after your patient?

Project status

Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

December 2015 – June 2016

Implementation sites

General Ward, Dubbo Health Service, WNSWLHD


Clinical Leadership Program


A point prevalence audit of omitted medication administration was conducted from December 2015 to January 2016. The pre-intervention audit of 53 patients with a total of 2061 charted doses indicated that 91% (n = 48) of patients had an omitted dose with an omission rate of 11.1% (n = 228).

Interventions were carried out over a period of four months, from February to May 2016. A post-intervention audit was undertaken in June 2016. It comprised 57 patients with a total of 2062 charted doses and showed that 56% (n = 32) of patients had an omitted dose. Dose omission rates were reduced from 11.1% (n = 228) to 4.8% (n = 99). Post-intervention data also indicated a reduction in critical medication omission rates, from 90% to 30.8%.

Documentation of reasons for withheld doses improved from 21% to 85%. The repeated point prevalence audit post-intervention indicated that 95.2% of patients had documentation stating they had received their medications or had clear documented reasons for omitted doses. The project also increased awareness of omitted medication administration and documentation, in nursing and medical staff.

Lessons learnt

  • Constant engagement with staff is required to make and sustain change.
  • Education is a critical to implementing change and increasing awareness.
  • Culture change takes time.
  • Time and workload constraints to sustain change can be a challenge.
  • Constant turnover of medical and nursing staff was a challenge.


  1. Graudins LV, Ingram C, Smith BT et al. Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications. International Journal of Quality Health Care 2015; 27(1): 67-74.
  2. National Patient Safety Agency. Rapid Response Report: Reducing harm from omitted and delayed medicines in hospital. NHS England; 2010.  

Further reading


Jin Wen Chan (Kelvin)
Deputy Director of Pharmacy
Dubbo Health Service
Western NSW Local Health District
Phone: 02 6809 8152 / 0415 063 550

Search Projects

Browse Projects

Submit your local innovation
and improvement project