SANTA CLARA VALLEY MEDICAL CENTER

Report ID: CRM711.02, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to follow their policy and procedure regarding "Mail-order Shipping Execution/Delivery Confirmation Tracking" for one of two sampled patients (2), when the hospital mailed Patient 2's medication to Patient 1. This failure resulted in the facility not being able to confirm if a medication was mailed to the correct recipient. Findings:The California Department of Public Health received a faxed report on 3/28/13 which indicated on 3/25/13 Patient 1 brought to the pharmacy a vial of insulin (medicine used to control blood sugar levels) which had Patient 2's name on it. Patient 1 stated she had received the vial by mail in January 2013, but did not realize the insulin vial did not belong to her. She had kept the vial in her refrigerator since she received it. On 3/24/13, Patient 1 went to use the insulin and realized the insulin vial belonged to another patient. Patient 1 brought the vial to the pharmacy to report the error.During an interview on 6/24/14 at 11:40 a.m., the pharmacy supervisor (PS) stated Patient 1 had brought a bottle of insulin to the hospital's outpatient pharmacy. Patient 1 informed the staff the insulin was for another patient. PS then stated Patient 1 received the insulin in January 2013. Patient 1 did not question why she had received the insulin without ordering it, and just put it in her refrigerator. PS also stated, Patient 1 had not kept the mailing package. PS further stated, Patient 1 did not look at the mailing label, and just opened the package and put the insulin in the refrigerator. A review on 6/24/14, of a copy of the label from the insulin Patient 1 had returned to the pharmacy, had Patient 2's name on it. During a telephone interview on 6/24/14 with PS and the pharmacy director (PD), PS stated the pharmacy had speculated the post office had delivered the medication to the wrong address, and the package was addressed correctly. PD stated, Patient 1 and Patient 2 had ordered their medications at separate times, and PD therefore did not believe it was a pharmacy error. PD further stated, the hospital thought it was a wrong delivery by the post office.When asked, the hospital was not able to produce a copy of either patients' mail order nor mail-out confirmation. The hospital could not confirm Patient 2's package was labeled with the correct mailing address. A review on 6/26/14 of the hospital's "Mail-order Shipping Execution/Delivery Confirmation Tracking" policy revised 12/2011 indicated, for refrigerated and non-refrigerated bulky items, use a tracking bar code for delivery confirmation and keep a copy for the record.

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 1 other violation. Note that these may be related to the same event: CRM711.01

6 other violations reported on the same date. Note that other citations may be about the same event: EGUY11.01, EGUY11.02, EGUY11.03, EGUY11.04, EGUY11.05, ITGS11.01