CORONA REGIONAL MEDICAL CENTER

Report ID: P77211, California Department of Public Health

Reported Entity: CORONA REGIONAL MEDICAL CENTER

Issue:

Based on observation, interview, and record review, the facility failed to ensure the confidentialtiy of one patient (Patient 1) was maintained when an IV bag for another patient (Patient 2) had information for Patient 1 taped on it. This failed practice resulted in the potential for physical, emotional, and financial harm to Patient 1.Findings:The record for Patient 2 was reviewed on April 12, 2012. Patient 2, a 37 year old female, was admitted to the facility on October 14, 2011, for an elective abdominal hysterectomy.The nursing record indicated on October 16, 2011, at 5:30 p.m., the RN identified the wrong IV fluid had been hung by the previous (night shift) nurse. According to the record, Patient 2 became aware of it at 6 p.m., and the CN and the HS spoke to the patient.During an interview with the Dircetor of MS on April 12, 2012, at 11:10 a.m., the Director stated she was aware of the incident, and it had been investigated. The Director stated a Pyxis label (printout from the ADC) for Patient 1 had been taped to the IV bag that was infusing into Patient 2. She stated the IV solution that was infusing into Patient 2 was the correct solution, but the label had the wrong name.A picture of the IV bag was observed on April 16, 2012. A plastic IV bag (that had been hung on Patient 2) had a pyxis label taped on it that contained the following confidential information for Patient 1:1. Name;2. DOB; and3. Account Number.The IV bag with the incorrect label had been hanging on Patient 2's IV pole and infusing into her since 10:30 the night before (for seven hours).

Outcome:

Deficiency cited by the California Department of Public Health: Patients' Rights