HIQA: Medication near misses 'were not being reported' at University Hospital Limerick

Inspector found 'inherent weaknesses' in hospital's medication safety systems

Fintan Walsh


Fintan Walsh

HIQA: Medication near misses 'were not being reported' at University Hospital Limerick

UL Hospitals Group chief clinical director, Prof Paul Burke

UNIVERSITY Hospital Limerick was found to have “inherent weaknesses” in its medication safety, following an announced inspection by the Health Infor-mation and Quality Authority.

The health watchdog stated in a report this week that it identified “a wide range” of medication safety risks, and that the “collective nature” of the risks “presented potential risks to patients”.

It was found that governance arrangements in medication safety at UHL was “fragmented” and “underdeveloped”.

“This has resulted in the relative lack of effective systems in place to ensure minimum standards of safety and quality are met relating to medication safety,” it stated.

The inspector noted the low level of reporting of medication-related incidents, and stated that medication near misses “were not being reported”.

This meant that medication risks “could not be understood, recorded, escalated or mitigated effectively” by UHL staff. 

“Senior management recognised that this level of reporting was not in line with internationally accepted norms and were aware of the need for improvement.”

However, Hiqa stated that after viewing medication incidents to date, they noted there “was a lack of notable improvement in reporting rates”.

Other issues included: the hospital’s drug and therapeutic committee had “poor compliance” with its own terms of reference; a lack of current policies, protocols and guidelines to support clinical staff in safe prescribing and administration of medication at ward level; there was a lack of formalised medication reconciliation process.  

A spokesperson for the UL Hospitals Group said that it welcomed the Hiqa report, following its inspection on May 18.

Welcoming the report, UL Hospitals’ chief clinical director, Prof Paul Burke said: “We are committed to ensuring the highest standard of care for all our patients and acknowledge the requirement for a dedicated medication safety officer for the UL Hospitals Group.

“This will enable us to adopt a more focused approach to medication safety across all our hospital sites and we remain committed to progress this strategy over the coming months.”

The inspector was complimentary of a range of quality improvement initiatives that were already implemented at UHL.

“Hiqa also commented positively on UHL’s arrangements to educate and counsel patients about their medicines, and to train and educate medical and nursing staff.

“UL Graduate Entry medical School senior educators are committed to producing medical graduates with strong awareness of medication safety culture and medication related risks,” the spokesperson said. 

UHL was commended for its delivery of safety alerts in relation to insulin and paracetamol.

Hiqa noted UHL’s introduction of a new drug ‘kardex’, a procedure for administering and prescribing medication.