Poor medication safety standards at UHL children’s unit

University Hospital Limerick

Minimum standards of medication safety were not adhered to at University Hospital Limerick (UHL) when the Health Information and Quality Authority (HIQA) inspected two wards – one of them a children’s unit – at the hospital last year.

During the course of 34 countrywide inspections, HIQA identified specific high risks in six hospitals, UHL being one, according to an official report just published.

In an announced inspection of the Rainbow Childrens Ward and ward 3b in the neurological and stroke unit, HIQA inspectors found that mistakes and “near misses” were under-reported.

The inspection team took issue with governance of medication safety, which was described as “fragmented in approach and underdeveloped,” resulting in a “relative lack of effective systems in place to ensure minimum standards of safety and quality are met relating to medication safety”. 

Outlining the reason for such inspections of hospitals, HIQA states: “While most medication errors do not result in patient harm, medication errors have, in some instances, the potential to result in catastrophic harm or death in patients”. 

The report stated that a “strategic, planned approach to managing medication safety outlining clear objectives, goals or plans was not in place at the hospital at the time of the inspection.

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“It was of concern that a tertiary hospital providing complex clinical care did not have a sufficiently defined medication safety programme in place. Moreover, it was not apparent that medication safety was adequately supported at executive management level at the hospital”. 

In response, hospital management provided HIQA with a quality improvement plan to address the risks identified.

But the report states that “there are no timelines associated with the completion of this quality improvement plan,” and said that this needed to be addressed “as a matter of priority”.  

“HIQA also notes that the hospital had endeavoured to strengthen governance arrangements in recent months,” and the report added that a follow-up inspection would be needed.

“However, the hospital demonstrated awareness of many of the inherent weaknesses in the existing medication safety systems and had recently acted to address some of the deficiencies identified.

“By way of example, inspectors were informed by senior managers that recruitment for a new medication safety co-ordinator post was in progress. Practices to enhance medication safety in the Paediatric Unit were identified during the inspection”. 

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