This week's publication of an independent report into medication errors at Galway Hospice is welcome and should provide a basis for a reopening of its in-patient unit, which has not been in a position to admit new patients for more than nine months. The report outlines in detail the conclusions of a group of experts who examined 17 identified medication incidents.
They concluded that no error had occurred in two cases; that there was an error resulting in no harm to the patient in 10 instances; and that five errors had caused patient harm. In four cases, emergency medical intervention was necessary in order to sustain life.
A number of breaches of the Misuse of Drugs Act (1988) are identified in the report; this represents an especially serious finding for a unit with a necessarily high use of opiates and other controlled drugs. The experts also found that the inventory checking of controlled drugs was not carried out to the standard required by An Bord Altranais, the regulatory body for nursing practice. On clinical governance, the report made recommendations to the board of directors of the Galway Hospice. It identifies a requirement for it to carry out a needs assessment and a validation and classification of its mission.
The identification of systematic error within the operation of the Galway Hospice reflects a clash of cultures: modern palliative medicine seeks to improve the quality of life of the cancer patient by engaging with him early in his illness, while the more dated concept of terminal care focuses on the dying patient. It would be helpful for other hospices to clarify their mission in this light.
The expert group's model report echoes many of the concerns raised in the Brennan Report on Financial Management and Control Systems in the Health Service. It analyses real examples of medical and nursing error, some of which came close to causing permanent patient harm. The analysis underlines the importance of completing national research into healthcare error recently announced by the Minister for Health and the urgent need for such error to be managed in a proactive way.
Without the whistle-blowing of Dr Dympna Waldron, consultant in palliative medicine with the Western Health Board, not alone would the patients of Galway Hospice continue to be at risk, but none of the nationally important issues of governance and healthcare error would have come to light. She deserves recognition for her bravery and integrity in prioritising the safety of her patients above any self-interest. Both her actions and the expert report merit further study by health professionals and healthcare administrators alike.