‘Near misses’

In a separate incident last spring one patient was sent home from a Ward in Altnagelvin with his own medicines and also with those of another patient who had a similar sounding name.

The man took both sets of medicines for four days before returning to the Londonderry hospital. He complained and a full medication review was carried out by the Trust.

According to documents released to the Sentinel under Freedom of Information (FOI) legislation, a meeting of the Trust’s Acute Governance Committee in March 2010 discussed a raft of ‘near misses’ - events that would have led to personal harm but for luck or good management - that occured over a single one-week period.

The minutes of the meeting state: “A one-week snapshot identified 264 ‘near misses.’ This has been discussed at the Drugs and Therapeutics Committee and a series of sessions are planned with Medical Education Leads to discuss key themes.”

According to the Trust’s own guidance for reporting incidents, examples of ‘near misses’ include the incorrect prescription, dispensing or administration of drugs as well as their administration to the incorrect patient.

And the Department of Health, Social Services and Public Safety’s (DHSSPS) ‘Safety First: A framework for Sustainable Improvement in the HPSS’ guidance document says an error, incident or near miss is “any event or circumstances that could have or did lead to harm, loss or damage to people, property, environment or reputation.”

Further documents released to the Sentinel reveal that during the quarter immediately following the identification of the 264 ‘near misses’ an Incident/Near Miss analysis found 548 events had occurred across the Western Trust area.

An Acute Services Directorate Governance Report for the quarter April 2010 to June 2010 highlighted hundreds of incidents with the highest reporting categories being patient accidents (160 plus) and clinical care issues (150 plus).

Broken down by sub-division there were 50 Incidents/Near Misses in Diagnostics and Clinical Support; 282 in Emergency Care and Medicine; 15 in Pharmacy and HDSU services and 201 in Surgery and Anaesthetics.

Further broken down by specialty the highest number of incidents in the quarter were recorded in General Medicine (116) and A&E, AMU/CDU/CAU and Urgent Care (115).

The Risk Management section of the report goes on to outline what lessons were learned from the various incidents which occurred.

It notes that on one occasion incorrect patient details were carried on an electronic discharge letter and that this was only picked up later by a clinical pharmacist.

Another patient received incorrect doses of four medicines during admission to the Erne Hospital due to inaccurate information being delivered by GP practice staff.

Consequently it was emphasised to staff that all telephone information must be backed up by an accompanying fax.

Incidents also occurred in the dispensing of drugs and a communication handover document also had to be produced to ensure important information was not lost on transfer from Ward to Ward.

The increase in medication incidents generally also resulted in moves to highlight to all staff the importance of the five ‘rights’ of drug administration, namely, the right patient, time, drug, dose and route.

Separate to drugs administration there were also concerns raised over an increase in the amount of patients pulling out their own breathing tubes and an increase in the amount of patients whose Central Venous Catheters (CVC) were accidentally removed.

The Trust report also shows that 39 complaints were received from patients during the quarter.

One of those complaints was that of the Altnagelvin patient sent home with two sets of drugs.

“Patient sent home from ward in Altnagelvin with his own medicines and medicines dispensed for another patient with a similar sounding name. Both lots of medicines had been dispensed correctly. The patient took both sets of medicines for four days before coming to hospital. Full medication review was carried out. Learning around checks involved when giving a patient his dispensed medicines on discharge,” the report reads.

Other Trust patients complained about the attitude of staff and a leadership day was established for Ward Managers “to address serious issues relating to staff attitude following a complaint.”

The report also notes that “communication/staff attitude has featured in a number of complaints across the Trust.”

Further documents released to the Sentinel show that the Trust’s “Draft Protocol for the Management of Medication Incidents” was discussed by a meeting of the Trust’s Medicines Governance Group in September 2010 when it was agreed the protocol should be revisited due to its having been ongoing for 18 months.

The Sentinel asked the Western Trust for comment. At the time of going to press no comment was yet available.