Serious failings at York Hospitals Foundation
2:14pm 27th January 2012
(Updated 2:27pm 27th January 2012)
Serious failings for York Hospitals Foundation regarding the security of medicines.
An investigation's revealed a third of NHS trusts surveyed were below par.
In York, fridges on labour and theatre wards were unlocked.
But officials from the hospital have defended their actions.
They've release this statement:
"Since this audit in August 2011 a risk assessment of the two fridges in maternity has been carried out.
"The fridges do not contain controlled drugs and are only accessible with a swipe card. T
"Therefore the view of our pharmacists undertaking the risk assessment, is that current practice is safe."
Meanwhile, Leeds Teaching Hospital has also been named and shamed in this investigation by Sky News.
There were 19 unaccounted-for controlled drugs losses there last year.
The hospital has said it's "extremely small quantities" of controlled drugs that we have been unable to account for.
Background informtaion for Sky News investigation
A Sky News investigation has uncovered serious failings surrounding the security of medicines and controlled drugs in British hospitals.
A third of NHS trusts surveyed had audits showing that either medicines were not locked away; missing drugs were unaccounted for or medications were administered by unauthorised staff.
The findings come in the wake of an incident at Stepping Hill hospital where six people died after saline solution was contaminated with insulin.
Named and shamed, see the full list of hospitals contacted by Sky News here:
A bag of medication was left on the ward overnight and not transferred to the drugs cupboard.
The hospital stated: "Bradford Teaching Hospitals takes the issue of drug storage very seriously and has strict policies and auditing procedures in place.
"This was a rare incident which was fully investigated and staff were reminded of the correct procedure to follow."
Barnet & Chase Farm
Of the areas audited, 48% did not have up-to-date signatory lists.
Controlled drugs were administered by unauthorised nurses.
Fifteen per cent of wards failed to audit twice daily.
The hospital stated: "Where we find non-compliance, the Trust puts the appropriate action plan in place to ensure minimal risk to patients.
"Clinical pharmacists are working with individual wards and departments to feed back the results of their audit and take appropriate actions to correct the deficiencies found.
"Additionally, we now include the monitoring of controlled drugs as part of our monthly clinical indicator audits with our matrons."
Bart's & The London
Some wards were using tape and elastic bands to secure medicine lockers.
Faulty locks were not being repaired.
The hospital stated: "We are replacing all faulty medicine lockers with larger, lockable cabinets so that medicines can be held securely in one place.
"We expect to be 100% compliant by March 1, 2012. We have reminded staff of the importance of ensuring cabinets are kept locked at all times with additional checks on a daily basis."
Blackpool Fylde & Wyre
Twenty-three per cent of ward areas were unlocked.
Eighty-nine per cent of medicines storage rooms were unlocked.
In 89% of cases the storage area room temperature was not monitored.
In 45% of cases medicines were stored on the work bench.
In 37% of cases there were no current stock list of medicines held in the department.
In 34% of cases medicine cupboards were not clearly labelled.
In 57% of cases the intravenous fluid storage area was not lockable.
In 68% of cases the intravenous fluid area was not locked.
In 45% of cases medicines were being stored on the work bench.
The hospital stated: "The Trust takes patient safety extremely seriously and carries out regular audits to ensure the safe storage and handling of controlled medicines.
"The audit includes a list of mandatory checks and additional checks aimed at giving added assurance."
Central Manchester Hospitals
Fifty-eight per cent of medicine refrigerators were unlocked.
The hospital stated: "As ward and pharmacy checks of controlled drugs are frequent and rigorous documentation and process controls are in place around controlled drugs, we do not undertake a formal audit.
"Pharmacy safe-management of controlled drugs is detailed through a range of procedures and our arrangements are inspected by the General Pharmaceutical Council Inspectorate.
"Our last inspection was September 2010."
Forty-four per cent of wards didn't have all cupboards locked.
The medicine fridge was unlocked on 88% of wards.
The hospital stated: "This is very crude, snapshot data from a year ago, for example some of our wards contain unlocked drug access cupboards and fridges in a security controlled or locked room."
City Hospital's Sunderland
Twenty-three per cent of areas were not recording controlled drug entries properly.
The hospital stated: "This 23% is just an initial administrative non-compliance with new procedure not a stock discrepancy.
"This first audit identifies an initial implementation problem and allows us to address and fully complete the changes in these areas."
Cambridge University Addenbrookes
Ninety-three per cent of insulin fridges were left unlocked.
Fifty-seven per cent of insulin was out of date.
The hospital stated: "We have driven through significant improvements since this information was collected in May 2010 and carried out a further audit in August 2011 which showed 85% of fridges were locked and 88% had temperature monitoring.
"We have also reduced the number of wards holding insulin stock and reminded staff to regularly check expiry dates."
Dartford and Gravesham NHS Trust
Intravenous cupboards did not have functional locks.
The hospital stated: "We take the security of medicines extremely seriously at the hospital.
"Medicine security is under constant review by pharmacy staff who regularly visit wards to ensure that medicines are stored appropriately.
"This particular storage check, on one ward, identified that some IV medicines were being held in an unlocked drawer in a clinic treatment room on that ward.
"Immediate action was taken to place the drugs in a locked cupboard. This rolling programme of medicine security checks continues."
Doncaster and Bassetlaw Hospitals
Forty-two per cent of refrigerators were unlocked.
The hospital stated: "Since this audit was undertaken, the Trust has issued a revised medicines management policy (May 2011), which makes more explicit the requirement for fridge monitoring.
"The audit tools have been reviewed and a robust education program for all nursing staff has been implemented. Ward and department managers are required to make a declaration that their area is compliant with the Trust policy."
Heart of England NHS Trust
Sixty per cent of missing drugs were unaccounted for.
The hospital stated: "We take the safety of our staff and patients very seriously and our controlled drugs stock levels are checked at least once daily by two registered nurses.
"Any discrepancies in stock reconciliation are fully investigated and this includes completion of statements from staff.
"Overall the feedback from the CQC was that the Trust's controlled drugs governance appears to be very good and in a six-month period where we treated over 170,000 patients on our wards, 30 incidents were reported.
"Our nursing teams remain vigilant to ensure that any missing tablet or ampoule is investigated."
King's College London
All drugs cupboards locked in only 7% of cases.
Fifty-one per cent of cupboards storing injectable medicines were unlocked.
In 57% of cases staff were not asked for ID.
The hospital stated: "The audit also shows 100% of controlled drug cupboards are locked. Nursing staff check the security of controlled drugs every 24 hours. Senior staff assess drug security as part of regular visits to clinical areas.
"We investigate any adverse incidents involving controlled drugs to ensure lessons are learned and our systems are improved as a result.
"All wards are swipe access only, which only authorised staff can gain entrance to."
Luton & Dunstable
Intravenous fluids were largely stored in unlocked areas.
There was a failure to challenge unknown individual opening doors in the clinical area.
There was a failure to challenge an unknown member of staff not wearing ID entering clinical rooms and opening drawers.
There was poor compliance with the best practice requirement to lock clinical rooms.
The hospital stated: "Although there is currently no requirement for IV fluids to be kept in locked areas we're reviewing whether all medicines and IV fluids could be made more secure via an electronic security system that can be accessed only by hospital staff.
"We are also reminding all staff to be vigilant and to challenge unknown people, including unknown staff, who try to access restricted areas of the hospital."
Liverpool Women's NHS Trust
Twenty-seven per cent of areas didn't have some form of security.
In 13% of secure areas the keys were left in a designated location rather than held by a member of staff.
Intravenous fluids were stored on open shelving.
The outer door accessible to patients and public, rendering any unsecured storage "Red" rated.
The hospital stated: "The results (of this audit) were presented to the Clinical Governance Committee in November 2011 and a re-audit conducted in December 2011 which shows areas without security have reduced from 27% to 12%.
"The Trust however is not complacent and will continue to work with staff to reinforce the importance of safe storage of medicines through audit, training, spot checks and education."
Leeds Teaching Hospital
There were 19 unaccounted-for controlled drugs losses.
The hospital stated: "Leeds Teaching Hospital has excellent storage and security arrangements, robust assurance mechanisms and conducts frequent audits.
"The very small number of cases in which we have been unable to account for controlled drugs relate to extremely small quantities."
Milton Keynes Hospital
There was no central controlled drugs audit for 12 months.
The hospital stated: "There was a lapse in (controlled drugs audits) during 2011, which has now picked up. The audits recommenced this year.
"Drug checks are carried out on the wards every day and this is monitored by the matrons as part of their regular duties.
"If an issue or discrepancy is identified, it is then fed into our usual risk reporting processes. This ensures the director of nursing and the chief pharmacist are aware and the incident is then investigated accordingly."
Mid Cheshire Hospitals
The drugs fridge was not secure in 55% of wards.
The hospital stated: "All drugs fridges in the Trust are stored in lockable rooms, accessible only to relevant staff via a swipe card or key code.
"Following the initial audit in September 2011, we issued notification to all staff advising them of the correct procedures in regards to the safe storage of medicines.
"A follow-up audit found 78% of medical fridges were locked following increased security awareness.
"Further action plans have now been put in place across the Trust to address any outstanding potential drug security issues."
Mid Essex Hospital Services Trust
An access code was written next to a lock.
An unauthorised individual went unchallenged in the medicines area.
The hospital stated: "The issues raised in the July 2011 audit were actioned immediately and are monitored regularly by our pharmacy staff.
"We undertake regular audits for the safety and security of medicines every six months and anything raised during the audit is dealt with and actioned as a matter of priority.
"This compliance was confirmed in the January 2012 audit."
Fridges were locked in only 37% of cases.
Diluents were stored in original packaging in only 23% of cases.
The hospital stated: "Following the incident at Stepping Hill Hospital last year we immediately undertook an audit of ward medicine storage, and identified issues in need of attention.
"All necessary actions have now been put in place.
"Patient safety at Northampton General Hospital remains our highest priority."
Royal Free Hampstead
No clinical audit was done.
The hospital stated: "The Royal Free has robust policies and procedures in place to ensure medicines and controlled drugs are stored and secured to the relevant NHS standards and that we carry out regular checks on these processes."
In 37% of cases medicines were not locked away (February 2011).
The hospital stated: "An independent medicines management audit has been recently undertaken at Stepping Hill Hospital by NHS Audit North West.
"The report is still at draft stage, but the summary is as follows: 'A significant level of assurance has been given on the adequacy and operating effectiveness of controls in place within the areas of the medicines management function reviewed.'"
In 46% of cases medicines were unsecure.
In 54% of cases the fridges were unlocked.
The hospital stated: "There has been an improvement on compliance since an audit took place in 2011. We are 100% compliant for securely locking controlled drugs and 100% compliant for keys being held by appropriate members of staff.
"All fridges are locked in locked clinic rooms and keys for the clinic rooms are held by the nurse in charge."
Southport and Ormskirk
Thirty-nine per cent of intravenous fluids were stored in boxes on the floor.
Zero per cent of intravenous fluids were locked away.
Twenty-two per cent of cupboards were unlocked.
The hospital stated: "All the Trust's intravenous fluids are stored appropriately in designated areas, usually in a private room behind the nurses' station.
"During an audit a proportion of lockable medicines cupboards will always be found to be unlocked because they are in use at the time by clinical staff."
Cupboards were unlocked in 29% of cases.
Forty per cent of fridges were not temperature monitored.
Sherwood Forest trust were unavailable for comment.
Seventy per cent of cupboards were unlocked - improved to 20% on a second audit.
The hospital stated: "The initial audit in July 2011 identified areas where improvements in security of medicine storage could be made, and these were immediately actioned.
"Subsequent audits have demonstrated improvements in the security of medicines across the Trust.
"The Trust remains vigilant in this area, and will continue to undertake these audits on a regular basis ensuring patient safety remains the highest priority."
Thirty-three per cent of fridges were unlocked.
The hospital stated: "Following the audit we asked every clinical area to review its procedures for locking cupboards and fridges and feed back details of action they had taken to our pharmacy team. This work was completed by mid-December."
York Hospitals Foundation
Fridges on labour and theatre wards were unlocked.
The hospital stated: "Since this audit in August 2011 a risk assessment of the two fridges in maternity has been carried out. The fridges do not contain controlled drugs and are only accessible with a swipe card, therefore the view of our pharmacists undertaking the risk assessment is that current practice is safe."
Wirral University Teaching
Thirty-three per cent of fridges were not locked.
In 36% of cases fridges were at the wrong temperature.
The hospital stated: "We have a robust policy for the safe and secure handling of medicines and procedures for ensuring that managers and all staff who prescribe, dispense or administer medicines, are familiar with it.
"Regular internal audits are carried out to ensure the policy is being adhered to.
"A detailed and extensive action plan to address these issues was implemented which resulted in significant improvements in all relevant areas."
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