Recently my son was minutes away from being injected with a vaccine that the doctor claimed was perfectly safe for his condition but preferring to do our own research and quickly reading the complex manufacturers instructions we realised there was an issue the doctor or the clinic had not spotted.

What unfolded was a joke – the clinic lacked the facilities to cope with a serious reaction that was inevitable given the type of injections provided, there was completely different opinions on agreed practice between clinic owner, nurses and doctor, and the correct procedure had not been followed because the doctor was fairly new.

Eventually we got an apology because the situation was very close to being a serious problem but we were more concerned about all the other kids who would come after our child.

The problem was classic IQ mis-management.

The clinic posted out a questionnaire months before that the parents filled in and brought on the day, this was used to gauge what procedure to follow in the event of special cases eg. allergies etc.

What we discovered was the questionnaire was incomplete and the clinic themselves claimed that “most people forget anyway”, so there was clearly no IQ controls to ensure that the carer completed the form correctly.

After I calmed down I explained a simple new approach which would take all of 60 seconds to complete and guarantee no more kids would go through what our child did. It was so simple it was laughable but they rang me that night to say it was being introduced.

The lesson in all this as ever is that IQ management is not about tools and technology but common-sense approaches with appropriate governance and stewardship.

The clinic had singularly failed to govern their process and left it to individuals to fabricate a process that was doomed from inception because there were potentials for failure at every point in the information chain.

Sadly it always seems that it takes someones suffering to allow the flood-gates of common-sense to rush in and rectify a problem that often costs nothing at all to fix but a hell of a lot more when it goes wrong.

STATEMENT BY BEAUMONT HOSPITAL RE OMBUDSMAN’S REPORT
The Office of the Ombudsman issued a report this morning which highlighted a complaint against Beaumont Hospital regarding the circumstances in which an unprescribed dosage of medication was given to a patient. In her press release, the Ombudsman made reference to an audit of the Kardex system at Beaumont. A figure of 4.3% was given for Kardex transcription errors.

For purposes of absolute clarity, Beaumont Hospital points out that this audit was of approximately 170 reported medication events over a period of two years. This showed there were seven reports of errors made in the transcription of information between Kardex. This is the 4.3% referred to by the Ombudsman and is not 4.3% of all medications administered. It should also be noted that the audit was not of the hospital’s full Kardex system.

There are approximately 500,000 prescriptions written in Beaumont each year and approximately 4.5 million administrations of medication under these prescriptions.