Pilgrim Hospital criticised on medicine management again

The Care Quality Commission’s latest report on the trust’s Pilgrim Hospital found a series of errors which it said meant patients were not protected against medicine risks and drugs were not always kept safely.

The watchdog said it had “major concerns” over the way medicines were managed at the same hospital in August 2011.

Inspectors found patients were not given drugs on time, rooms where medicines were stored could not be locked and nurses were not recording medication properly in patient records.

In one incident a dose of medicine for a “very poorly” child was given four hours too late, with both the error or the fact that the drug had been given going unrecorded by the nurse despite guidelines stating the drug becomes less effective if given more than 30 minutes late.

Two senior nurses admitted borrowing medicines from each other until the pharmacy could supply them. Pharmacists complained they did not have enough time to thoroughly check medicines for all new patients. One pharmacist told inspectors: “We are a stressed department trying to do our best.”

The CQC said staff could not be confident about the security of medicines in some rooms which were not locked and the temperature of medicine fridges had not been recorded.

Patients told the CQC they were happy with the care they received although inspectors found several people had not been informed about the medicine they were currently receiving or those which they were expected to take when discharged. One man was on a continuous fluid drip, but had no idea why.

Inspectors visited six wards at the trust in May, and published a report on its findings in July.

A trust spokesman said: “We are pleased the report reflects significant improvements made in the management of medicines since this outcome was last reviewed in 2011.

“However we continue to work hard to ensure we deliver consistently high standards of care across all our services.”

In the last six months the hospital has launched a new safety and quality dashboard and created a medicines safety group and a medicines management committee. It has also introduced an e-learning tool for medicines which allow staff to carry small cards with safety notes printed on them for reference.