Nursing Compliance with Medication Administration and Management of Omitted Doses: A Clinical Audit in Two Hospital Wards

Background: Medication administration is a critical component of patient safety. Nurses in hospitals serve as the final checkpoint in the medication use process, ensuring that prescribed medications are administered correctly and safely. Failure to administer medications as prescribed or delays in obtaining medications can lead to treatment failure and adverse patient outcomes, particularly with high-alert medications.

Objective: This clinical audit aimed to evaluate nursing compliance with medication administration practices, documentation standards, and the management of omitted medication doses in two hospital wards.

Methods: A retrospective audit of 60 medication charts (Kardex) from two hospital wards was conducted using a structured audit tool evaluating nine medication safety criteria: patient identification, review of medication orders, verification of dose and time, documentation of medication administration, documentation of omitted doses, communication of omitted doses to the healthcare team, medication availability, allergy status verification, and patient education and consent.

Results: Full compliance (100%) was observed for patient identification, documentation of medication administration, and patient consent. However, deficiencies were identified in several areas. 25% of medication charts contained incomplete prescribing instructions, 48% showed discrepancies related to dose or timing verification, and 42% of nurses documented omitted doses without informing the clinical team. In addition, 25% of nurses did not obtain unavailable medications from pharmacy promptly, resulting in missed doses for up to two days. Allergy documentation was absent in 16.7% of medication charts.

Conclusion: While nurses demonstrated strong adherence to patient identification and documentation standards, gaps remain in medication verification, communication regarding omitted doses, and medication supply management. Pharmacist-led education and improved multidisciplinary collaboration are essential to enhance medication safety and reduce omitted doses.