Scripps Mercy Hospital

Report ID: 1OPP11.01, California Department of Public Health

Reported Entity: SCRIPPS MERCY HOSPITAL

Issue:

Based on interview and record review, the hospital failed to ensure that staff implemented it's policy pertaining to medication security and storage, for 1 of 2 sampled Patients (Patient 1). A technical partner (TP 1) inadvertently gave Patient 1's home medications to the wrong patient.Findings:A review of Patient 1's medical record was initiated on 10/18/12, at 8:15 A.M. Patient 1 was admitted to the hospital on 6/1/12, with a chief complaint of abdominal redness and swelling, per the Discharge Summary, dated 6/3/12. Per the Discharge Summary, Patient 1 was discharged on 6/3/12.According to Patient 1's "Patient's Own Medications Envelope" (an inventory of the patient's home medications at admission), dated 6/1/12, the following medications were listed: Insulin (medication to treat high blood sugars) syringe, hydrocodone (used to treat moderate to severe pain), hydromorphone (also known as Dilaudid - a narcotic used to treat moderate to severe pain), Oxycodone (a narcotic pain reliever, used to treat severe pain), Quinapril (blood pressure medication), methotrexate (used to slow the growth of certain cells in the body), ketoprofren (nonsteroidal anti-inflammatory drug), Ferrous Sulfate (iron used to treat anemia), Citalopram (anti-depressant medication), Furosemide (used to treat edema), Folic Acid (vitamin supplement), multi-vitamins, Amiodarone (medication used for irregular heart beat), Bayer Aspirin (relieves pain and reduces fever), Vitamin D3, Prevacid (antacid- suppresses acid secretion in the stomach) and Prilosec (antacid). Per the same form, a note from pharmacy staff indicated that on 6/3/12, Patient 1's narcotics were given to a licensed staff on the 6th Floor.A review of Patient 2's medical record was initiated on 10/18/12, at 8:15 A.M. Patient 2 was admitted to the hospital on 5/31/12, with a chief complaint of respiratory distress per the Discharge Summary, dated 6/2/12. Per the Discharge Summary, Patient 2 was discharged on 6/2/12.A review of the hospital's policy entitled "Medications: Orders, Administration, and Documentation," effective date of 2/2012, was conducted. The policy indicated patient's own medications will be inventoried on the "Patient's Own Medication Envelope," and returned to the patient at the time of discharge. Per the same policy, it stipulated that "Medications are safely and securely stored throughout the hospital."An interview and joint record review with technical partner (TP 1) was conducted on 11/8/12, at 3:10 P.M. TP 1 stated that she assisted with the discharge of Patient 2. She stated that she picked up Patient 2's home medications from the pharmacy on 6/2/12, but did not verify that the home medications given to her by the pharmacy technician belonged to Patient 2. She acknowledged that she signed the hospital's form entitled "Patient's Own Medications Envelope" for Patient 2, without checking and verifying she had received the correct patient's home medications. TP 1 stated that she returned to the 6th Floor and reported to Registered Nurse (RN 1) that she had Patient 2's home medications from the pharmacy. She stated that RN 1 had told her that Patient 2 was ready for discharge and she handed the bag of home medications (belonging to Patient 1) to Patient 2. An interview with RN 1 was conducted on 11/20/12, at 1:44 P.M. RN 1 stated that she recalled discharging Patient 2 on 6/2/12. She stated that she had provided TP 1 with Patient 2's (Patient's Own Medications Envelope) slip to retrieve the patient's home medications from the pharmacy. She acknowledged that she did not check or verify that the bag of home medications retrieved by TP 1 from the pharmacy, belonged to Patient 2. She stated that she should have checked to ensure that the correct home medications were given to the right patient.An interview and joint record review with the 6th Floor Manager was conducted on 11/20/12 at 2:04 P.M. The 6th Floor Manager acknowledged that TP 1 did not follow the hospital's process when staff retrieved home medications from the pharmacy. She acknowledged that both TP 1 and RN 1 did not ensure that Patient 2 received the correct bag of home medications at discharge, in accordance with the hospital's policy. As a result, she acknowledged that Patient 1's home medications were given to the wrong patient.

Outcome:

Deficiency cited by the California Department of Public Health: Nursing Service Policies and Procedures.

Related Reports:

The report containing this deficiency also includes information about 3 other violations. Note that these may be related to the same event: 1OPP11.02, 1OPP11.03, 1OPP11.04

1 other violation reported on the same date. Note that other citations may be about the same event: GZZK11.01