medical equipment being prepared by a pharmacist

Critical Care

Can recording date-of-opening of oral liquids help reduce waste on adult intensive care units?

The work described here was shortlisted for the UKCPA Best Abstract award at the Pharmacy Together 2019 conference.

Most critical care patients have enteral feeding tubes sited for feed and drug administration. As a result, many liquids are required to be kept as stock. Recording the date-of-opening (DOO) of a liquid is essential to enable an expiry date check, whilst ENFit® bottle adapters (bungs) should be utilised to reduce the risk of wrong route administration, improve administration accuracy and reduce waste, as highlighted by the 2007 National Patient Safety Agency alert.

The stability of oral liquids is altered on opening; in-use shelf life may be significantly shorter than the manufacturer’s expiry date, increasing risk of waste. Recording the DOO of a liquid is therefore essential to enable an expiry date check. 

An audit was conducted as a follow-up to a quality improvement project on the General Intensive Care Unit to improve stock liquid management and to determine current practice on the other adult ICUs. 

The objectives were to evaluate the number of opened stock liquids with a completed DOO label, and to determine the number of opened stock liquids that contain an ENFit® bung. 

The audit identified a significant level of wastage across the ITUs, primarily due to poor DOO recording which resulted in products being unusable.

The audit standards were set as 100 percent of opened stock liquids to have the DOO label completed, and 100 percent of opened stock liquid to contain an ENFit® bung. 

The audit included stock oral liquids in the stock cupboards across the adult ITU’s (n=4) and at patient’s bedsides (n=49) over a three-day period in May 2019. A re-audit was undertaken three weeks later after a nursing awareness campaign on the importance of correct liquid management was conducted through the ITU matrons and social media. 

Data was prospectively collected by two pharmacists; one per audit cycle using the same method with the data collection tool designed. 

At baseline, it was found that just over half (56%) of opened stock liquids had a completed DOO label, and that 15 percent contained a bung. Upon re-audit, we found an increase in completed DOO labels (78%) and stock liquids containing a bung (38%). Only around 10 percent of opened bottles achieved both standards at baseline, but this had increased to 33 percent on re-audit. 

A total of 32 bottles were identified for destruction due to the lack of a date-of-opening at baseline. That wastage was calculated at £212.10. Re-audit identified 16 bottles for destruction, with a wastage cost of £105.77. 

The baseline audit identified a significant level of wastage across the ITUs, primarily due to poor DOO recording which resulted in products being unusable. Minimising medicine waste is a clear aim of the recent NHS Long Term Plan, with medication optimisation a key focus. Ensuring safe medication use is essential to improve clinical outcomes and achieve financial goals.

The short audit periods were recognised as a limitation, potentially affecting data accuracy and generalisability. In order to reduce wastage, a stock list review was undertaken to identify liquids which could be switched to crushable or dispersible tablets. Continuous nurse education is also required.


This work was presented as a poster at the Pharmacy Together 2019 conference, organised by UKCPA and Pharmacy Management.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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