HIQA recommends promoting a national strategic approach to reduce the amount of medication errors in public acute hospitals

Date of publication:

The Health Information and Quality Authority (HIQA) has today published an overview report of the findings of its medication safety monitoring programme from November 2016 to October 2017. Thirty-four public acute hospitals were inspected as part of HIQA’s programme during this period.

HIQA found that although the majority of hospitals had some form of medication safety programme in place, one in three hospitals had no formal strategy or plan to direct medication safety improvement activities. HIQA recommends that a national approach to strategic planning for medication safety is required to reduce the number of medication errors and improve patient safety with the use of medicines.

HIQA identified that although some Irish hospitals have performed well in implementing medication safety programmes, there were widespread inconsistencies and unwarranted variation in medication safety systems across hospitals nationally.It is estimated that one medication error occurs per hospital patient per day, equating to three million medication errors in Irish hospitals per year.

Aoife Lenihan, Inspector Manager in Healthcare Regulation at HIQA said “As modern medicine continues to advance, increasing medication treatment options are available for patients with proven benefit for treating illness and preventing disease. This advancement has brought with it an increase in the risks, errors and adverse events associated with medication use. Therefore, it is essential that hospitals have necessary elements in place to ensure patient safety in line with best practice and research.”

During this programme HIQA identified areas of good practice in relation to medication safety and areas that require improvement to ensure medication safety systems were effective in protecting patients. The findings included:

  • Twenty-one hospitals inspected had a functioning drugs and therapeutics committee to oversee medication safety. The other thirteen hospitals required strengthening of their governance structures to support a medication safety programme.
  • One in three hospitals inspected had no formal strategy or plan to direct medication safety activities.
  • Only 13 hospitals had a documented list of approved medications (formulary) and system for evaluating new medicines in place.
  • There were disparities in clinical pharmacy service provision, both in how they were provided and the resources allocated to them.
  • Thirteen hospitals were completing medication reconciliation on admission with three hospitals completing medication reconciliation on admission and discharge.
  • There was significant underreporting of medication incidents in some hospitals.

Aoife Lenihan continued: “There is a fundamental requirement to improve medication safety to protect patients from harm from medication errors as although most errors do not result in patient harm, medication errors have the potential to result in catastrophic harm or death and the majority are preventable."

Overall, there is considerable potential for improving medication safety systems by learning from the work and efforts of other hospitals. While collaboration between hospitals is happening in relation to improving medication safety, a greater focus on collaboration at a hospital group and national level would reduce duplicated effort, and lead to faster progression in driving collective improvement in medication safety.


For further information please contact:

Marty Whelan, Head of Communications and Stakeholder Engagement, HIQA

01 814 7480 / 086 2447 623, mwhelan@hiqa.ie

Notes to the Editor:

  • HIQA monitors medication safety in hospitals against the National Standards for Safer Better Healthcare. This programme aims to examine and positively influence the adoption and implementation of evidence-based practice in relation to medication safety in public acute hospitals in Ireland.
  • Medication safety has been identified internationally as a key area for improvement in all healthcare settings. In March 2017 the World Health Organization (WHO) identified Medication Safety as the theme of the third Global Patient Safety Challenge. The WHO sets out its specific aim to ‘reduce the level of severe avoidable harm related to medications by 50% over five years globally.
  • HIQA’s evidence-based monitoring programme involved announced inspections of public acute hospitals in Ireland. It was developed to examine and analyse systems in place to support safe medication practice in line with international best practice and research.
  • Extensive research internationally has identified medication usage as the leading cause of unintended harm for patients availing of hospital care.
  • The Institute of Medicine estimated that one medication error occurs per hospital patient per day, equating to three million medication errors in Irish hospitals per year Irish Medication Safety Network).
  • Medication-related incidents include incorrect dosage, missed medication and incorrect or not reconciled medication on admission or transfer or discharge.