"Drug errors whilst an inpatient"

Dear falconxe33,

I am sorry to hear about your experience with medications whilst under the care of our services at Fiona Stanley Hospital.

We continually strive to provide excellent patient care, including the involvement of patient-initiated care within the rehabilitation services. As part of this ongoing quality improvement, clinical errors such as medication errors are tracked in detail to allow ongoing coordination of care resources and process improvements.

Your feedback has been communicated to the ward teams within the State Rehabilitation Service at Fiona Stanley Hospital and any notified errors that occurred during your time on the wards will be reviewed.

I also encourage you to contact the Fiona Stanley Hospital Patient & Family Liaison service on 6152 4013 so we can further look into all the circumstances surrounding your case.

We thank you for the time you’ve taken today to alert us to this situation.

Kind regards,

Neil Doverty

Dear falconxe33,

Thank you for your correspondence.

The Chief Pharmacist was able to confirm that as an organisation Fiona Stanley Hospital has a number of strategies in place to identify and mitigate the risk of medication errors, these include:

Separation of Prescribing, Dispensing and Administration functions wherever possible e.g. having a doctor prescribe the medication, having the pharmacist review medication charts for inpatients and dispense prescriptions on discharge/for outpatients and having nursing staff administer the medications which helps to identify potential medication errors and prevent them from reaching the patient.

Reviewing medication incidents and near-miss incidents that occur in the hospital at both an organisational and local level and identifying trends in incidents and initiating strategies to prevent these from happening again e.g. through the Medication Safety Committee where high-risk medication incidents reported via our Clinical Incident Management System are review monthly, at a ward level where errors are addressed with individual staff and the wider ward team via education initiatives and through having clinical staff as medication safety champions (quality portfolio holders) across the hospital.

FSH has a very good reporting culture in terms of medication incidents however it is not possible to review medication incidents that are not reported by either the patient or hospital staff, unfortunately. Numerous education initiatives on medication safety for doctors, nurses and pharmacists e.g. orientation sessions on medication safety which includes examples of real-life incidents, toolbox sessions on specific high-risk medications like anticoagulants and insulin also occur regularly and targeted education occurs based on specific ward/area requirements. We have policies and guidelines to support safe medication prescribing, dispensing and administration processes such as the Medication Administration Policy which specifically in relation to the issue raised by this patient does outline that the right documentation is required which includes ‘sign the medication chart to indicate that the medication was administered to the patient’.

Regular audits are also undertaken which cover prescribing, dispensing and administration practices such as the National Standard Medication Chart Audit, Medication Reconciliation Audit etc.

We do understand that this will require ongoing monitoring, however, are confident in the ability and dedication of our staff to eradicate or at least minimise drug errors.

Kind regards,

Neil Doverty

Dear falconxe33,

Medication is given as per the Fiona Stanley Hospital Medication Administration Policy and Procedure.

If a patient is to self-administer medication (as is the case in rehabilitation patients), the chart is signed after administration.

Please contact the Fiona Stanley Hospital Patient and Family Liaison Service on 6152 4013 if you would like to discuss further.

Kind regards,

Neil Doverty.