Revealed: errors threatened patients’ lives

FOUR patients needed life-saving treatment because of medical errors at the Galway Hospice, an independent report has revealed.

The hospice has been unable to provide full services since last May when its consultant, Dr Dympna Waldron, made allegations about the incorrect dispensing of drugs and stopped referring patients to its beds.

The hospice set up an independent review group, chaired by Ian Carter, St James’s Hospital deputy chief executive, and it published its report yesterday.

It investigated 31 medication errors between January 2002 and May 2003 and found:

* No errors in two cases.

* 23 errors where the patient was unharmed.

* Six errors where the patient was harmed.

Two patients were given excess doses of hydromorphone, a derivative of morphine.

Both patients required resuscitation. Another patient was given a tenfold overdose of methadone by nursing staff and also had to be revived.

A nurse accidentally gave a patient 89,000 units of the blood-thinning drug Tinzaparin instead of 8,900 units but there were no adverse effects.

There was no common system in the hospice for updating inpatient charts, so nurses and doctors often had to guess what instructions meant.

Nursing staff interviewed for the report commented on the ‘busyness’ of the hospice inpatient unit, where occupancy rates rose from 60% in 1993 to 99% after the appointment of a consultant in 1998.

“Throughout the interviews, it was clear this significant workload change had not been anticipated or planned for,” the report said.

The independent report said there was a failure of communication between medical and nursing staff and “little evidence of a process to properly evaluate medication errors”.

As a result, the hospice’s actions to prevent recurrence were “largely ineffectual”.

The report made 65 recommendations including:

* A system of double- checking the administration of drugs.

* An investigation into staff resources and a structured induction programme for all new staff .

The Galway Hospice Foundation said it was determined to implement all the recommendations.

It added the completion of the report was a stepping-stone to recommencing consultant referrals by the consultant to the 12 beds in the hospice.

It said in a statement: “The foundation regrets any inconvenience or distress that has been caused to patients and their families and wishes to acknowledge the continued support of the public.”