Reducing dose omission of prescribed medications in the hospital setting: a narrative review

Medication error, including dose omission of prescribed medications, can lead to adverse outcomes for hospital patients. Consequently, there is an onus on healthcare staff to understand the causes of these errors and introduce proven methods to prevent their recurrence. This paper presents a review of the literature on the reported causes of, and suggested solutions to, omitted administration of prescribed medications in hospital inpatient settings. Dose omission of prescribed medication has been shown to be one of the commonest causes of medication error in inpatient populations. Unavailable medication, poor communication and poor documentation of administered medications are commonly cited explanations. Institutions have implemented strategies, which have been shown to reduce the incidence of omissions. Such strategies include changing pharmacy processes to ensure medication is available when required; introducing electronic prescribing; encouraging improved communication between healthcare professionals involved inmedicationmanagement; and educating staff about the importance of administering all prescribed medications, documenting when medications are administered and reporting all medication omissions.