Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis

Int J Qual Health Care. 2013 Oct;25(5):564-72. doi: 10.1093/intqhc/mzt044. Epub 2013 Jun 5.


Objective: To investigate the changes in overdue doses rates over a 4-year period in an National Health Service (NHS) teaching hospital, following the implementation of interventions associated with an electronic prescribing system used within the hospital.

Design: Retrospective time-series analysis of weekly dose administration data.

Setting: University teaching hospital using a locally developed electronic prescribing and administration system (Prescribing, Information and Communication System or PICS) with an audit database containing details on every drug prescription and dose administration.

Participants: Prescription data extracted from the PICS database.

Intervention(s): Four interventions were implemented in the Trust: (i) the ability for doctors to pause medication doses; (ii) clinical dashboards; (iii) visual indicators for overdue doses and (iv) overdue doses Root Cause

Analysis: (RCA) meetings and a National Patient Safety Agency (NPSA) Rapid Response Alert. Main outcome measure(s) The percentage of missed medication doses.

Results: Rates of both missed antibiotic and non-antibiotic doses decreased significantly upon the introduction of clinical dashboards (reductions of 0.60 and 0.41 percentage points, respectively), as well as following the instigation of executive-led overdue doses RCA meetings (reductions of 0.83 and 0.97 percentage points, respectively) and the publication of an associated NPSA Rapid Response Alert. Implementing a visual indicator for overdue doses was not associated with significant decreases in the rates of missed antibiotic or non-antibiotic doses.

Conclusions: Electronic prescribing systems can facilitate data collection relating to missed medication doses.

Interventions: providing hospital staff with information about overdue doses at a ward level can help promote reductions in overdue doses rates.

Keywords: clinical; decision Support Systems; electronic prescribing; medical order entry systems; medication errors; medication therapy management.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anti-Bacterial Agents / therapeutic use
  • Hospitals, Teaching / standards
  • Hospitals, Teaching / statistics & numerical data
  • Humans
  • Medical Order Entry Systems
  • Medication Errors / prevention & control*
  • Medication Errors / statistics & numerical data
  • Medication Systems, Hospital / organization & administration
  • Medication Systems, Hospital / standards
  • Quality Improvement* / organization & administration
  • Retrospective Studies


  • Anti-Bacterial Agents