Omitted and Delayed Doses

NPSA/ RRR 009/ 2010Reducing harm from omitted and delayed medicines in hospital - List of critical medicines

The National Patient Safety Agency have advised that NHS organisations should identify a list of critical medicines where timeliness of administration is crucial and make staff aware of the list and what to do when a medicine has been omitted or delayed, in order to minimise risks.

List 1 (General clinical)
Anticoagulants (oral and parenteral)
Anti-infectives
Analgesics
Anti-anginal nitrates
Antiepileptics (for epilepsy)
Bronchodilators
Corticosteroids
Eye drops
Immunosuppressants
Insulin
Oral antidiabetic medication
Oral chemotherapy medication
Oral contraceptives
Parkinson’s Disease medication
Resuscitation medication
‘Stat’ doses (oral and parenteral) / List 2 (Mental health orientated)
Alcohol detoxification regimens
Antidepressants (with short half-life)
Antimanic drugs (lithium)
Antipsychotics (clozapine)
Anxiolytics (acute psychotic episodes)
Substance dependence medication

It is a Trust requirement that all non-administration of medication MUST be notified via the risk management system Safeguard unless there is a documented clinical reason for that non-administration.

Staff are reminded that it is important to prescribe and administer all medication appropriately and to ensure that the prescription chart is fully completed on every occasion not just for the medicines highlighted above.

For full information regarding all of the NPSA medicines related alerts please visit the NPSA website.

The following table lists some of the common critical medicines but is not exhaustive. Consult the most recent BNF for other medicines in the categories.

NPSA/2010/RRR009: List of critical medicines where delay or omission of administration poses a risk to patient safety

Medication Type / Medication List / Indication of Medication / Potential risks as consequence of delay
Prescribed dose missed at:
time on chart / within 2 hrs / DOSE OMITTED
Anticoagulants / enoxaparin, dalteparin, warfarin, apixaban/dabigatran/rivaroxaban / DVT, PE / Minor impact / Potential clotting event
Anti-infectives / amoxicillin, cephalexin, erythromycin,
nystatin, didanosine / Acute & severe microbial, fungal, viral, HIV, protozoal infections / Depends on indication, risk high with first doses missed, or with elderly patients & patients with co-morbidities
Analgesics / buprenorphine, codeine, fentanyl, morphine, oxycodone, tramadol / Pain: Mild to severe with pyrexia, severe chronic, breakthrough / Minor impact / Severe discomfort Withdrawal effects
Anti-anginal nitrates / GTN S/L tablets and spray / Acute angina / Significant or catastrophic anginal attack
Anti-epileptics / carbamazepine, gabapentin, lamotrigine levetiracetam, phenytoin, valproate / Epilepsy– all seizure types / Minor impact / Significant epileptic seizure
Bronchodilators / salbutamol, salmeterol, terbutaline / Acute asthma/ COPD / Significant respiratory impact
Corticosteroids / prednisolone / Acute respiratory conditions / Exacerbation / Respiratory impact
Eye drops- Glaucoma
Eye drops – Uveitis / betaxolol, carteolol, latanoprost
atropine, cyclopentolate / Acute glaucoma
Acute uveitis / Exacerbation / Possible damage to eyes
Immunosuppressants / cyclosporin, tacrolimus / Transplant anti-rejection / Minor impact / Possible rejection
Insulin –short acting / Actrapid, Novorapid, Humalog / Hyperglycaemia/ketoacidosis / Significant impact in ketoacidosis event
Insulin – intermed/long / Levemir, Lantus, Novomix, Humulin / Hyperglycaemia / Minor impact / Significant impact of high glucose levels
Injection- antidiabetic / liraglutide, exenatide / Hyperglycaemia / Minor impact / Significant impact of high glucose levels
Oral Antidiabetic / gliclazide, metformin, sitagliptin / Hyperglycaemia / Minor impact / High glucose levels
Oral Chemotherapy / busulphan, chlorambucil, methotrexate ` / Active tumour treatment / Minor impact / Impact- disease progession
Oral contraceptive / Cerazette, Microgynon, BiNovum / Contraceptive / Minor impact / Pregnancy risk
Parkinson’s Drugs / Bromocriptine, carbegoline,co-beneldopa, co-careldopa, pergolide, pramipexole, ropinirole, rotigotine / Parkinson’s disease /  Symptoms / Complications and longer length of stay
Resuscitation Drugs / adrenaline/epinephrine / CPR / anaphylaxis / Significant or catastrophic failure of resuscitation
Alcohol detoxification / chlordiazepoxide, diazepam, oxazepam, Pabrinex, thiamine / Withdrawal syndrome, seizures, delirium tremens, Wernicke’s / Severe withdrawal symptoms / Significant impact– seizure/ Wernickie’s
Antidepressants / paroxetine, venlafaxine / Depression / Minor impact / Discontinuation syndrome
Antimanic drugs / lithium / Acute Mania / Minor impact / ↓lithium levels
Antipsychotics / clozapine / Treatment resistant schizophrenia / Minor impact / ↓levels (>48 hrs : re-titration)
Substance dependence / buprenorphine, methadone naltrexone, / Opioid withdrawal / Minor impact / Severe withdrawal

Staff must seek advice from medical staff or a pharmacist if any of these drugs are going to be or have been omitted or delayed.

Please note that non-administration of medicines is considered a drug error and must be reported.