Safe Medicines Practice Group
Medication Safety Alert
Rapid Response Report NPSA/2010/RRR009
Reducing harm from omitted and delayed medicines in
hospital
Introducing the Safe Medicines Practice Group
This is a multi-disciplinary group whose remit is to review incidents reported via the Datix system.
The group looks at common themes, medications and systems involved in reports
The group addresses issues with a view to reducing the incidents and near misses that arise.
It is a subgroup of the Drug and Therapeutics Committee.
The group also looks at and responds to National Patient Safety Agency (NPSA) alerts
Introducing the issue
Medicines are often omitted or delayed in hospital for a variety of reasons. For some critical medicines or conditions
delays or omissions can cause serious harm or death.
Between September 2006 and June 2009, the NPSA received reports of 27 deaths, 68 severe harms and 21,383
other patient incidents relating to omitted or delayed medicines. Of the 95 most serious incidents, 31 involved antiinfectives (antibiotics and antifungals), and 23 involved anticoagulants.
The NPSA issued a Rapid Response Report NPSA/2010/RRR009 in February 2010 which lists actions required to
be taken to reduce risks with omitted and delayed critical medicines, one of the actions is to identify a list of critical
medicines where timeliness of administration is crucial.
Overleaf is a list of critical medicines and potential outcomes if the medicine is delayed.
Obtaining medicines out of hours
Below is a list of options available to access these medicines out of Fieldhead Hospital Pharmacy opening hours : Emergency cupboard at Fieldhead Hospital, this is on Chantry Ward.
 Borrowing policy between wards, see Medicines Code.
 Reuse of patient’s -own medication. Patients/carers are to be encouraged to bring in supplies of patient’s own
medicines for re-use on wards.
 Inter Trusts borrowing of medicines, between SWYPFT and Mid Yorkshire Trust.
 On-call pharmacist available via Pinderfields General Hospital switchboard.
 Use of FP10HNCs (community prescriptions) and community pharmacies, after consulting on call pharmacist.
There is a supply of FP10HNCs in the Emergency Cupboard on Chantry Ward at Fieldhead Hospital.
Opening hours on Saturday and Sunday of
Boots Chemist,
Saturday 8.30am to 5.30pm
26-28 Kirkgate,
Sunday 10.30amto 4.30pm
Wakefield,
WF1 1UP
Telephone number 01924 376181
In Calderdale and Kirklees there are emergency cupboards on site and a weekend and on-call pharmacy service is
available from the local acute trust pharmacy departments. These services have access to the mental health on call
pharmacist for advice
Many of the items below are included on ward stock lists and most of the others are available in emergency cupboards.
For all other items not available by the above routes, either for new admissions or established treatments, contact the
on call pharmacist. Please note the pharmacist is not on site and may not be able to answer the phone immediately.
Ensure you leave a message with your name and a contact number as the pharmacist cannot identify missed calls.
Pharmacy departments will prioritise the dispensing of items on the critical list.
Class of medicines/or
generic name of medicine
Antibiotics
Anticoagulants
Examples
Potential outcomes if delayed/additional comments
amoxicillin,
ciprofloxacin,
clarithromycin, flucloxacillin
Low Molecular Weight
Heparin(enoxaparin/Clexane)
Oral anticoagulants(warfarin)
Omitted or delayed medicines will prolong the duration of
infections, some will be more critical than others
depending on the infection and clinical indicators
Includes either treatment or prophylactic doses.
Omitted doses may result in low INR so increasing the
risk of clotting, leading to DVTs, PE’s or other thrombotic
events such as stroke.
Includes any medication to control seizures. Missed
doses of anticonvulsants may lead to epileptic seizures.
It is important to be aware of the indication for these
drugs as they are also used as mood stabilisers in
bipolar affective disorder. If more than 5 days of
lamotrigine has been omitted the dose needs to be
retitrated as there is a risk of toxic epidermal necrolysis
(see Trust lamotrigine communication ).
Anticonvulsants
carbamazepine, sodium valproate,
phenytoin, lamotrigine,
leviteracetam
Antidiabetic Drugs
gliclazide,metformin,glimepiride,
exenatide
naloxone, flumazenil, procyclidine
efavirenz,zidovudine
salbutamol, terbutaline
Actrapid, glargine, Insulatard
Antidotes
Anti Retrovirals
Bronchodilators
Insulin
Posterior Pituitary
Hormones/Antagonists
Palliative-Anticipatory
Medicines
Parkinson’s Disease
Medication
Resuscitation Medicines
Steroids
Immunosuppressant and
anti-rejection drugs
Oral anticancer treatments
Methotrexate
DDAVP(desmopressin)
diamorphine, midazolam, hyoscine
butylbromide etc.
Co-beneldopa, co-careldopa,
pramipexole, ropinirole
adrenaline, oxygen
prednisolone, hydrocortisone,
methylprednisolone,
dexamethasone
azathioprine, ciclosporin
Procyclidine-Oral/ IM
Includes any medication for HIV treatment
Especially short acting and synthetic insulins. Missed
doses of insulin will result in raised blood sugar level
which may have serious consequences.
DDAVP-Oral/IM
See care of the dying pathway
Missed doses result in a significant worsening of
symptoms causing major distress to the patient.
Unable to resuscitate
Deterioration of condition eg asthma
May lead to rejection
Potent Opioid Analgesics
MST, Zomorph, Oromorph
Medicines with short halflives
Benzodiazepines
venlafaxine, paroxetine
Diazepam, clonazepam,
temazepam
Delay in treating cancer can lead to mortality
Requires specific monitoring and incorrect administration
may have potential serious consequences
Missed doses or delayed doses may lead to the need for
re titration resulting in worsening of the mental state and
prolonged hospital stays.
If 48 hours or more of medication has been missed the
dose needs to be re titrated. Re titration is required
because of cardiovascular risks and risk of seizures
If 4 days or more of medication has been missed then
this is classed as a treatment break and the blood
monitoring frequency may have to be altered.
(For further information see Trust clozapine policy).
It is important to ensure patients have a valid blood
result.
Lithium levels are required to be within a defined range
to be effective. Relapse occurs quickly if lithium is
omitted and suicide risk increases significantly.
Sudden withdrawal of opioid analgesics may result in
withdrawal effects as well as causing suffering to the
patient due to increase in pain levels.
Missed doses will rapidly lead to withdrawal effects due
to the short half life
Rapid withdrawal of long term benzodiazepines may lead
to significant withdrawal effects including seizures.
Glucagon
GlucaGen HypoKit
Hypoglycaemia
Clozapine
Lithium
Produced by Martine Wilkinson, Senior Clinical Pharmacist
Approved by the Safe Medicines Practice group February 2011