Table 2.
Omission Category | Reason | Frequency (%) |
---|---|---|
Unexplained or Unknown | Not charted—reason unknown ∗ | 282 (37.3) |
Not on administration record for date/time† | 31 (4.1) | |
Partially Explained | Held, reason not documented | 80 (10.6) |
Patient post operative/unable to swallow | 7 (0.9) | |
Fully Explained | Held for medical reasons | 165 (21.8) |
Patient refused | 55 (7.3) | |
Ordered and discontinued within 60 minutes | 29 (3.8) | |
Patient off floor | 24 (3.2) | |
Patient discharged | 24 (3.2) | |
Patient taking nothing by mouth | 22 (2.9) | |
Discontinued prior to shifted schedule | 19 (2.5) | |
Drug not available on ward | 9 (1.2) | |
Patient near terminal/care withdrawn | 6 (0.8) | |
No intravenous access | 3 (0.4) | |
Total | 756 (100) |
∗ Not charted—reason unknown coded for orders that were transcribed to the medication administration record but were neither charted as given nor charted as not given.
† Not on administration record coded for orders that did not appear on medication record (and also not charted). The order may not have been transcribed to the medication administration record.
The reason for the omissions in the Unexplained or Unknown category is unknown.
Omissions in the Partially Explained category were not fully documented. The omission was assumed to be intentional because the dose was circled as held or the chart notes indicated the patient was immediately post operative and not taking oral fluids.
Omissions in the Fully Explained category were fully documented and with appropriate reasons for holding or omitting the dose.