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Reducing inappropriately missed doses

Simple interventions designed to increase adherence to an existing hospital surgical “nil by mouth” policy were effective and sustainable, and incurred no additional costs

By David Chalkey and Jon Beard

Simple interventions designed to increase adherence to an existing hospital surgical “nil by mouth” policy were effective and sustainable, and incurred no additional costs

David Chalkley lead pharmacist for surgery and critical care and Jon Beard chief pharmacist, both at taunton and somerset nhs foundation trust

In February 2010, a National Patient Safety Agency report highlighted the potential harm caused to patients by inappropriate omitted medicines. And, in 2009, research suggested that the risks of withholding beta-blockers in the perioperative period was associated with rises in mortality. 

Through anecdote and incident review, pharmacists began identifying causes of missed doses. Some of these related to incorrect interpretation of existing trust policy.

A short audit of surgical medication administration record (MAR) charts was undertaken and the most common reason for inappropriately withholding medicines was identified as “patient NBM” (nil by mouth), occurring most frequently on general surgical wards. Our project focused on reducing missed doses in the preoperative period in general surgery by addressing the misinterpretation of what was meant by “nil by mouth”.


Factors causing missed doses were identified and we then focused solely on ensuring that “nil by mouth” patients received their prescribed medicines inaccordance with the existing trust policy.

A set of solutions was proposed:

• Pre-existing bedside “nil by mouth” notices would be updated to include a patient’s oral intake status and a summary of relevant policy
• Nurses would be issued with credit card-sized policy summaries attachable to ID badges
• Nurses would receive a two-minute instructional briefing regarding the bedside notices and summary cards, key messages being that “nil by mouth” patients receive oral medicines with sips of water
• Breaches of policy would be reported as incidents

These solutions were then tested, modified and implemented throughout general surgery while measuring their impact on missed doses and capturing this data in a run chart.

Work began on a pilot ward, with selection based on the likelihood of ward staff and the project team working effectively together. Senior nursing staff and the anaesthetics lead were briefed. This group provided high level sponsorship and authority for project activity and was kept informed of progress.

Baseline “missed doses” data were collected from all 121 general surgical beds. A random number generator was used to select five patients daily, Mondays to Fridays, and a pharmacist examined their MARs to see if any medicines had been inappropriately withheld. Policy failure included:

• Medicines withheld inappropriately as judged by policy
• Failure to document the rationale for withholding
• Blank entries on the MAR

Results were plotted on a run chart. Data were expressed as a percentage of patients inappropriately missing one or more doses in weekly samples, eg, of 25 patients audited, if five missed one or more doses, 20 per cent were recorded as having inappropriately missed medicines. 

Eventually the run chart was analysed to determine whether the interventions had statistically significant impact on missed dose rates.

At the same time, “plan, do, study, act” (PDSA) rapid cycle testing was used on the pilot ward to develop the “bundle” of interventions. For instance, the clarity of both the bedside notice and policy summary card were tested with nursing staff. After several tests the bedside notice, summary card and instructional brief were ready for introduction to the pilot ward. A new notice was placed by each bed and each nurse received a summary card and instructional brief. Further small changes were made following constructive feedback.

Once the first three changes were implemented on the pilot ward, similar high level sponsorship was sought from senior nursing staff on the remaining four wards and the changes were rolled out.

Ward pharmacists provided new, bank and agency nurses with summary cards and instructional briefs. The final intervention involved reporting policy breaches as incidents.


Following implementation of the three interventions the average missed dose rate fell from 13.3 per cent (SD 7.6 per cent) to 4.8 per cent (SD 4.0 per cent) and, after the introduction of incident reporting, fell further to 1.4 per cent (SD 2.6 per cent).


Before 2010, missed doses had low organisational priority. However, project baseline data revealed a significant problem. We took the approach of trying to reduce all instances of missed doses by strengthening process and procedure and raising awareness of the dangers of missed doses rather than focusing on high risk drugs specifically.

Overall the project was not complex; nor did it require additional resources, relying instead on regular pharmacist ward visits. The interventions were effective at changing behaviour, through education and challenging policy deviation. This was particularly satisfying because initially some pharmacists had thought the interventions too simple to work. The data collection and analysis was statistically valid and reviewing five drug charts daily was easily sustainable.
It is worth noting that, during the project, changes occurred in nursing practice that may have affected the project outcomes. These were the introduction of “nursing metrics”. The first of these was aimed at reducing the incidence of undocumented reasons for omitting medicines. The second was aimed at reducing blank MAR chart entries.

The contribution of these is difficult to quantify. However, falls in missed doses clearly corresponded to the implementation of the project intervention “bundle”, suggesting a causal link.


Simple interventions intended to increase the reliability of administration of medicines to surgical patients in the preoperative period were effective and sustainable with the need for minimal financial investment. This intervention bundle could be easily adapted and implemented in any ward where pharmacist visits occur daily.

The full paper, together with references and acknowledgements, is available on PJ Online at
Correspondence to: David Chalkley

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11119811

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