Medication safety in Kilkenny hospital needs ‘considerable improvement’

Governance arrangements relating to medication safety at a Kilkenny hospital requires “considerable improvement”, according a report from the health watchdog.

The Health Information and Quality Authority (Hiqa) said “overarching governance arrangements” relating to the management of medication safety at Kilcreene Regional Orthopaedic Hospital were “complex and confusing”.

An announced medication safety inspection was carried out at the hospital on June 14th. In its report, Hiqa said the “complex, fragmented and unsynchronised arrangements” viewed by inspectors had resulted in “inherent weaknesses in the management of medication safety at the hospital”.

The report added the arrangements represented “a latent risk that needs to be addressed as a matter of priority”.

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Kilcreene Regional Orthopaedic Hospital was previously a member of the HSE’s South Eastern Health Board, under the management of St Luke’s General Hospital in Kilkenny before transition to the South/South West Hospital Group.

The report said as a result of the geographical location and long-established links through previous group structures, both hospitals were working within “legacy arrangements” for some services while the new hospital group structures evolve.

“It was reported that responsibility and oversight of medication safety at Kilcreene Regional Orthopaedic Hospital rests with the General Manager of University Hospital Waterford,” the report stated.

“However, ambiguity amongst some senior managers and staff over who was the accountable person with ultimate responsibility for medication safety within the hospital was evident during interview.”

The report said St Luke’s General Hospital was responsible for the provision of pharmacy services to Kilcreene Regional Orthopaedic Hospital while University Hospital Waterford had overall accountability and responsibility for medication safety at the hospital.

Not evident

It said a formal medical safety strategy, programme or plan for the hospital was not evident at the time of the inspection.

Furthermore, it said there was a “relative lack of evidence of linkage or alignment” with any medication safety strategy, programme or plan in either St Luke’s General Hospital or University Hospital Waterford.

Hiqa found there was a “fragmented approach” to leadership, governance, oversight and support for medication safety at the hospital.

The report noted inspectors were informed by senior management that this deficit and the resulting potential for confusion were only “recently considered by the hospital” in preparation for the inspection.

Inspectors said there was a low number of medication related incidents and near misses reported throughout 2016 at the hospital.

It said as a result, key medication related risks were not being “understood, recorded, escalated or mitigated effectively by the organisation”.

“Low numbers of incidents reported does not necessarily mean a low number of incidents occurring,” the report added.

The report said that, following the inspection, the hospital and hospital group must focus its efforts to address the issues and its findings.

It also said they should work to ensure the necessary arrangements are in place to protect patients from the risk of medication-related harm, “through improved clarity around governance in the context of current rather than legacy arrangements”.