Years after a woman died as a result of a medication mix-up at an Okanagan hospital, an Interior Health Authority audit found there still exists a “moderate to high risk” to patients at its facilities.
Brenda Gaida, 40, was admitted to Vernon Jubilee Hospital in July 2007 for treatment of a skin condition for which she received a drug called methotrexate. Her health deteriorated and she died three months later at an Alberta hospital.
Her family claimed the cause of death was “methotrexate brain toxicity” due to excessive doses she received at VJH, according to a B.C. Supreme Court ruling issued this month, which confirmed a $440,000 judgment against Interior Health, the hospital and four doctors. The defendants admitted the drug was mistakenly given to Gaida daily rather than weekly.
Issues with medication management arise frequently. In 2011 alone, IHA reported 5,306 “medication related events” to a provincial database that tracks adverse events, near-misses and hazards, according to an internal audit completed Dec. 24, 2012, and obtained by the Penticton Western News through a freedom of information request.
Auditors assessed eight of the region’s largest acute care sites and found just 56 per cent compliance with “standard practices and policy,” and identified “multiple opportunities for substantial improvement,” according to the report.
“In internal audit’s opinion, there exists a moderate to high risk of significant patient harm associated with the current medication management practices as observed in selected medical surgical inpatient units.”
The report lists some breaches auditors uncovered, including:
n Medication carts, some of which contained controlled substances, left unattended in many hallways
n Six of eight sites did not waste narcotics according to policy, and some staff asked others to witness narcotics wastage after the fact
n Patient identification and allergy bands at all sites were not checked prior to administration of medication
n At all sites, medications were poured into cups and not labelled, nor were syringes, with the exception of those that were pre-labelled by the manufacturer
The audit cited six factors as the main causes of staff’s non-adherence to policy, such as stress from a heavy workload, distractions and interruptions, plus facility shortcomings like space limitations and technology failures.
Twelve recommendations for improvement are contained in the report, and IHA chief nursing officer Heather Cook said all are “completed or well underway at this point.”
Cook was unable, however, to quantify how much those measures have reduced patient risk.
“I couldn’t even begin to identify (that). I think that anytime medications are involved, it’s never a low risk,” she said.
“It’s a complex process in health care from the moment a physician determines that a medication is required, through all the steps that it takes until a medication is delivered to a nursing station and a nurse administers the medications.”
The audit determined staff at VJH met just 60 per cent of practice standards. The best was Cranbrook’s East Kootenay Regional Hospital, which scored 61 per cent.
The audit states that at VJH, “the best possible medication history (BPMH) was not consistently found on the chart and of those on the chart, medication reconciliation was completed for only a few patients. Pharmacy stated the delay of implementing the BPMH was due to the effort focused on opening the site’s new patient care tower.”
The audit also states, “the Pyxis machines had a one machine to 30 patients ratio compared to the recommended standard of one machine to 20 patients.”
Kevin Barry, who sits on the regional executive of the B.C. Nurses’ Union, noted that compliance scores were low across all sites, so “that leads me to suspect the issues are systemic. It’s not related to one facility.”
He also cited a shortage of staff and an increase in the number of very sick patients as factors affecting audit scores.
“In the ideal world, yes, all those standards could be followed. The problem is, in hospitals, you don’t operate in the ideal world,” Barry said.