Background In 2010 the National Safety Agency published a report on reducing harm from omitted and delayed medicines in hospital: ‘Missed Doses occur when a medicine is not given to a patient when prescribed and may result in harm’.

NBT invested in Patient Safety, including: the Safer Patients Initiative (SPI2) and the Southwest Quality and Patient Safety Improvement Programme (SWQPSI). There are various causes of missed doses, our initial focus was drug unavailability.

NBT was set targets by the local commissioning body of reducing missed doses by 20% by 2010/11, and a further 15% by 2011/12.

Purpose To reduce the incidence of missed doses due to drug unavailability. The objectives were to: Raise awareness of the effects on patients; Understand the reasons for missed doses and to introduce an e-audit tool for ward use.

Materials and Methods Using improvement methodology, tests of change were trialled and spread to 40 wards:

Phase 1: February 2010–July 2010:

We determined the criteria for missed doses and developed an e-audit tool using Plan Do Study Act (PDSA) cycles.

Phase 2: August 2010–April 2011:

The Ward e-audit tool was tested then spread; Wards were given a stock medication location report and Pharmacy prioritised missed doses.

Phase 3: May 2011–September 2011:

A Training package was introduced/spread and Ward Posters and Handover sheet were developed.

Phase 4: October 2011–August 2012:

Monthly run charts of results were shared with senior managers. Pink order slips and orange leaflets were introduced.

Results We achieved our target for 2010/11. The 1.95% target for 2011/2012 was more difficult but was achieved as shown in the table.

Conclusions In achieving our targets we improved communication and changed the culture from staff not unduly concerned with missed doses to staff taking action to reduce missed doses and improve patient care.

No conflict of interest.