SANTA CLARA VALLEY MEDICAL CENTER

Report ID: 7RWF11.02, 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 was inadvertently given Patient 1's narcotic medication. The failure resulted in Patient 2 receiving the incorrect narcotic medication. Findings:The California Department of Public Health received a faxed report on 11/1/13, which indicated on 10/28/13, Patient 1 went to the hospital affiliated-pharmacy to pick up his narcotic medication, Oxycodone. Pharmacy staff discovered Patient 1's medication had already been picked up on 10/25/13 by Patient 2, who had been prescribed the narcotic medication Dilaudid.During an interview on 8/20/14 at 2:50 p.m., the pharmacy assistant director (PAD) stated Patient 1 went to the hospital affiliated pharmacy to pick up his prescription medication. The pharmacy staff looked at the signature log and realized it had been given to Patient 2. PAD stated when Patient 2 had come to pick up his medication, the pharmacy technician (PT) had checked Patient 2's two identifiers then went to the locked cabinet for the medication and inadvertently grabbed the medication bottle intended for Patient 1. When PT returned to her computer, Patient 2's information was no longer on the screen. PAD further stated, PT accessed Patient 1's information, instead of Patient 2's, by using the information on the medication bottle, then PT scanned the barcode on the medication bottle, which was intended for Patient 1, and gave it to Patient 2. During a telephone interview on 8/20/14 at 3:10 p.m., PT stated she had asked Patient 2 for two patient identifiers, then went to the locked cabinet in the back of the pharmacy to get Patient 2's medication. PT stated when she returned to the computer she scanned the label on the medication bottle, but it would not scan, because while PT was away from the computer, another staff member had erased Patient 2's profile from the computer. PT then stated she used the information on the medication bottle to access the patient's information, but since she had inadvertently grabbed the wrong medication bottle, Patient 1's information came up on the computer. PT stated she compared the information on the bottle to the information on the computer and handed the medication bottle to Patient 2. PT stated she was not aware she had given the wrong medication to Patient 2 until her manager informed her.A review of a copy of a letter from the hospital to Patient 1, dated 11/1/13, indicated on 10/28/13, the hospital affiliated pharmacy staff realized they had inadvertently handed Patient 1's bottle of medication to Patient 2.A review of a copy of the hospital's 03/2012 "Prescription Pick Up/Pharmacy Beneficiary Signature and Relationship Requirement Log" policy indicated, locate prescriptions on the shelf based on the last two digits of the medical record number and last name, and compare patient's name and medication name on each bottle to those listed on the computer. The barcode on each prescription bottle must be scanned. If the barcode will not scan, you must type the prescription number from the bottle only into the computer.

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: 7RWF11.01

3 other violations reported on the same date. Note that other citations may be about the same event: 80V211.01, CKZM11.01, CKZM11.02