SANTA CLARA VALLEY MEDICAL CENTER

Report ID: Z2I411.03, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on interview and record review, the hospital's affiliated pharmacy failed to safely dispense prescription medication for one of two sampled patients (2), when Patient 2 inadvertently received Patient 1's medication. The failure resulted in Patient 2 receiving the incorrect medication. Findings:The California Department of Public Health received a faxed report on 10/15/13, which indicated on 9/28/13, Patient 2 went into the pharmacy to pick up his prescription medication and was inadvertently given Patient 1's medication bottle. The pharmacy staff realized the error on 9/28/13 and called Patient 2. During an interview on 9/10/14 at 1:55 p.m., the privacy officer (PO) stated on 9/28/13, Patient 2 went to the pharmacy to pick up his prescription medication, but was inadvertently given Patient 1's medication bottle. PO stated the pharmacy staff realized the medication error on 9/28/13 when Patient 1 went to the pharmacy to get her medication and the pharmacy staff realized her medication had already been dispensed.During an interview on 9/10/14 at 2:10 p.m., a pharmacy technician (PT) stated on 9/28/13, Patient 2 came to the pharmacy to pick up his medications. One of his medications needed to be generic, but it was a brand name. PT stated she was working on changing the brand name medication to generic. PT stated, while waiting for Patient 2's generic medication to be ready, PT started helping the next patient (Patient 1). PT stated while she was still helping Patient 1, Patient 2's generic medication was ready, so PT asked Patient 1 if she could finish helping Patient 2. PT stated Patient 2 was in a hurry and he grabbed the medication bottles off the counter including Patient 1's medication bottle. PT stated she did not notice Patient 2 had inadvertently grabbed Patient 1's medication bottle until it was too late and Patient 2 had left the pharmacy. Patient 1 did get her medication filled while she was still in the pharmacy. PT stated Patient 2 returned the next day to the pharmacy to get his medication. PT stated Patient 2 had disposed of Patient 1's medication bottle prior to returning to the pharmacy.A review of the hospital's 03/2012 "Prescription Pick Up/Pharmacy Beneficiary Signature and Relationship Requirement Log" policy indicated confirm pick up status by scanning the barcode on each prescription bottle. The patient must sign sticker, then the sticker is placed in the Signature Book.

Outcome:

Deficiency cited by the California Department of Public Health: Pharmaceutical Service General Requirements

Related Reports:

The report containing this deficiency also includes information about 2 other violations. Note that these may be related to the same event: Z2I411.01, Z2I411.02

1 other violation reported on the same date. Note that other citations may be about the same event: 5CID11.01