Missed Doses and Patterns of Refusal: Utilization of a Digital Dashboard to Address Patient Safety

Introduction: Medication safety within healthcare systems is critical to identify, mitigate, and prevent harm. St Bartholomew’s Hospital (SBH) utilises a medication safety dashboard to document missed or delayed medication doses for all hospitalised patients. The objective of this study was to identify and describe missed doses of medication at SBH.

Methods: Data from the QlikSense® dashboard was evaluated from July 2023 to June 2025, based on the date when a medication was first prescribed. A total of 78,435 missed medication doses were identified. The data set was refined to exclude all ‘prn’ medications (as needed/not scheduled) and isolate patient-refused doses of medications on the SBH Critical Medications List. A secondary analysis was completed to identify ‘habitually refused’ medications. The definition of ‘habitually refused’ was a medication being refused two or more times by a patient during their hospital stay.

Results: A total of 5,768 (7.4%) medication doses were identified as patient-refused. The top three medications that patients refused were enoxaparin, morphine, and oxycodone. Most patient refusals occurred in respiratory and oncology wards. There were 3,757 (65%) ‘habitually refused’ doses by a total of 410 patients. Enoxaparin was the most habitually refused critical medication, accounting for 1,304 (35%) refusals by 166 patients.

Conclusions: The data revealed that over 7% of all missed doses occurred due to a patient refusing prescribed, scheduled medications. This project highlights the need to further examine the patient refusal reporting system, communication protocols between hospital staff when a patient refuses a critical medication, and patient education strategies to reduce refused doses. Future medication safety research at SBH includes a focused review of habitual enoxaparin refusals and evaluation of the venous thromboembolism risk assessment protocol.