Medication errors in disabled centre

Health watchdog Hiqa has found “a significant number of medication errors” at a centre for people with disabilities, including instances where medication was found on the floor or had gone missing.

An inspection into the Camphill Community Grangemockler facility in Co Tipperary was triggered after Hiqa “received unsolicited information concerning a number of drug errors occurring in the centre and the staffing arrangements in place to provide a safe service to the residents”, according to a report published yesterday.

The facility, home to 19 residents at the time of the inspection, is operated by Camphill Communities of Ireland.

Of the five outcomes assessed in the inspection, four were found to have major non-compliances and the inspection report concluded “while the person in charge was responsive to the regulatory process and was making a concerted effort to provide safe, person-centred services with the limited resources she had available to her, the unsolicited information received by Hiqa was substantiated and residents were in receipt of a service that was unsafe and not adequately meeting some of their assessed needs”.

According to the inspection report: “On viewing a number of incident-report forms, the inspectors were concerned that a significant number of medication errors had occurred in the centre over the months of May, June, July and August 2017.

“Documentation retrieved by the inspectors informed that these errors included incorrect administration of medication, medication not being administered when it should, the use of p.r.n. medicine [pro re nata — taken ‘as needed’] not in line with strict administration protocols and medication going missing.”

It also found that the procedures in place for the ordering, storing and administration of medication were not safe and put residents at risk, noting “a significant amount of medication errors recorded in this centre over the last four months”.

It criticised the management and auditing systems: “On a number of occasions it was also recorded that medications were found on the floor or had gone missing.”

The report did acknowledge that the provider had given written assurances that all the shortcomings would be addressed and said the person in charge was aware of the issues at the centre and making every effort to address them, but “she was significantly challenged by the lack of resources at hand”.

Administration of medicine was also an issue at another facility, Centre 4 of the Cheeverstown House Residential Services (Senior Citizens) in Dublin 6, run by Cheeverstown House Limited. The inspection report noted that medication management in the centre “required significant improvement to ensure suitable practices relating to the storing, disposal and administration of medication”.

On entering one house, one inspector observed the medication press was open and unattended.

Hiqa published 22 inspection reports yesterday, with good practice in evidence in most centres.