Missing medications associated with centralized unit dose dispensing.

The reasons for missing medications in a centralized unit dose system were studied, and means of improving the situation were recommended. Reasons for missing medications included: insufficient or incorrect medications dispensed by the pharmacy, differences in interpretations of orders by pharmacists and nurses, administration of extra medication or incorrect doses, waste of medication, administration of medication to patients other than for whom it was dispensed, delivery to wrong nursing unit, pilferage, and requests by nurses for medication before the orders were received by the pharmacy. A procedure for checking medications in unit dose carts by pharmacy and nursing personnel was implemented. Before this procedure, the rate of missing medications was 0.93% of the doses dispensed; after the procedure, the rate was 0.33%. Other recommendations designed to prevent missing medications in this unit dose system are presented.