Causes of incidents of delayed or omitted medications – an interview study

Abstract Background Patient safety is a global health challenge. Incidents of delayed or omitted medication is one of the most common types of medication errors found in both retrospective and observational studies. This study aims to explore the underlying causes of incidents involving delayed or omitted medication administration in a hospital setting in Norway. Methods Nine semi-structured interviews with nurses working on medical, surgical, and psychiatric wards across three hospitals in Norway were conducted. Participants were selected through purposive sampling. Interviews were transcribed verbatim and analysed using systematic text condensation (STC) for inductive thematic analysis. Furthermore, the resulting themes were deductively mapped to the International Classification for Patient Safety (ICPS) framework to identify mitigating factors. Results Four main categories of contributing factors for omission incidents emerged: staff, patient, organizational, and external factors. Staff-related issues included procedural deviations and prioritization challenges, such as unchecked drug intake or prioritization of medication administration when shifts were busy. Patient-related factors involved health conditions such as swallowing difficulties. Organizational factors included task organization and workload, collaboration, workplace culture and feedback. Examples included confusion on responsibility for administration of non-tablet dosage forms. External factors included limitations in digital tools and equipment, such as medication administration records not being fully displayed on smaller screens. The ICPS framework assisted in contextualizing the findings and highlighted areas for targeted interventions. Conclusions The findings of this study have provided insights in nurses’ perspective on contributing factors for incidents of medication omission in hospitals in Norway. Medication omission incidents are multifactorial. Organizational factors were the most prominent topic in this study. Improvement of organization and underlying systems in response to incident reporting is key to avoid medication omission incidents and enhance patient safety.