An investigation into medication procedures at Galway Hospice has found that emergency intervention was required in four of 15 cases involving maladministration of drugs.
Patients were "harmed" in five of these 15 cases, but no patient died as a result of medication errors reported during the period January 2002 to May 2003.
The 12-bed hospice at Renmore, Galway, was closed to all new admissions in May last year because of concerns about medication procedures raised by Dr Dympna Waldron, the palliative consultant attached to it.
The Irish Hospital Consultants' Association (IHCA) said last night that the report justified the actions taken by Dr Waldron to ensure safe patient care at the Galway.
The review group, chaired by Mr Ian Carter, deputy chief executive of St James's Hospital, Dublin, looked at 31 medication incidents in all, including 17 reported from January 2002. It found there were medication errors in 15 of these 17 cases. In an additional 14 incidents it found that there was one case where an error caused harm, and 13 where there was error but "no harm".
Drug errors were caused by both nursing staff and medical staff, it says, and all patients and families affected were informed by the hospice at the time.
In two of the 17 instances analysed in the review, tenfold overdoses of drugs were given.
One of these overdoses occurred because the doctor making the prescription had left out a comma. One case involved use of agency staff who are not trained for this type of specialised care.
In another instance, a transcription mistake by a doctor resulted in an incorrect dosage of morphine.
Nursing staff noticed the mistake within 30 minutes of an infusion starting, and the infusion was stopped with no apparent ill-effects on the patient.
After being notified of the error, the doctor amended documentation using correction fluid and failed to sign and date amendments to the medical notes.
This was found to be in breach of medical policy and rendered the review group's investigation more difficult, the report states.
Several instances state that nursing staff did not follow doctors' procedures, while in one instance there was a conversion error by a doctor.
The four most serious cases involved emergency intervention to save patients' lives.
The review identifies six major causal factors contributing to the incidents, including failure to check procedures during administration of medication; absence of checking policy when prescribing upon admission, and when undertaking complex calculations for prescriptions; lack of knowledge about use of the drug hydromorphone; deficiencies in the design of the inpatient unit prescription sheet and absence of written procedures for all staff using this sheet; and a failure of communication between medical and nursing staff.
The review is critical of overall hospice management, but accepts that a new management structure is now in place.
It makes 65 recommendations, which the Galway Hospice Foundation says it is committed to implementing.
Progress on implementing the changes should be formally reviewed within three months of receiving the report, the review team says, and this should be undertaken again by an external group.
The Galway Hospice Foundation says that the review's completion is an "important stepping stone" in ensuring that referrals to the hospice can resume "as early as is practicable". It says it is discussing this with the Western Health Board, as services at the hospice are provided in partnership with the board.
Members of the independent review group chaired by Mr Ian Carter were: Ms Geraldine Murray, divisional nurse manager at University College Hospital and Merlin Park Hospital, Galway; Ms Kay Leonard, advanced nurse practitioner designate at St Luke's Hospital, Dublin; Mr Tim Delaney, head of pharmacy and director of accreditation at Tallaght Hospital, and Dr Nigel Sykes, medical director and consultant in palliative medicine at St Christopher's Hospice in London.
