The NPSA has issued a Rapid Response Report (RRR) highlighting the potential harm of omitted or delayed medicine doses. Between September 2006 and June 2009, the Agency received reports of 27 deaths, 68 severe harms and 21,383 other patient safety incidents relating to omitted or delayed medicines.

All organisations in the NHS and independent sector who admit patients for in-patient treatment are asked to:

1. Identify a list of critical medicines where timeliness of administration is crucial. This list should include anti-infectives, anticoagulants, insulin, resuscitation medicines and medicines for Parkinson’s disease, and other medicines identified locally.

2. Ensure medicine management procedures include guidance on the importance of prescribing, supplying and administering critical medicines, timeliness issues and what to do when a medicine has been omitted or delaye.

3. Review and, where necessary, make changes to systems for the supply of urgent medicines within and out-of-hours to minimise risks.

4. Review incident reports regularly and carry out an annual audit of omitted and delayed critical medicines. Ensure that system improvements to reduce harms from omitted and delayed medicines are made. This information should be included in the organisations annual medication safety report.

5. Make all staff aware that omission or delay of critical medicines, for inpatients or on discharge from hospital, are patient safety incidents and should be reported.