Search Privacy Violations, Breaches and Complaints
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SHARP CHULA VISTA MEDICAL CENTER
Cited by the California Department of Public Health for violations of California’s Health and Safety Code relating to medical privacy during an inspection that began on September 5, 2012. Also cited in 46 other reports.
Report ID: KQD811.03, California Department of Public Health
Reported Entity: SHARP CHULA VISTA MEDICAL CENTER
Issue:
Based on interview, record and policy review, the hospital failed to ensure that their policy and procedure pertaining to drug storage and security was implemented by the pulmonary department staff, for 1 of 2 sampled patients (Patient 1). A respiratory therapist (RT 1) inadvertently left Patient 1's prescribed respiratory medication in another patient's room. Findings:On 8/30/12 at 11:00 A.M., the hospital reported to the Department that RT 1 inadvertently left Patient 1's prescription medication (Advair Diskus- a controller asthma medication that combines two drugs into one inhaler) in Patient 2's room.A telephone interview with RT 1 was conducted on 9/7/12, at 10:00 A.M. RT 1 stated that she recalled administering Patient 1's nebulizer treatment and Advair Diskus medication on 8/24/12. She stated that she brought Patient 1's Advair Diskus medication into Patient 2's room and administered Patient 2's breathing treatments. She acknowledged that she inadvertently left Patient 1's Advair Diskus medication, which was in a ziplock bag with a label that contained the patient's full name, medication, dose and instruction for use on it. She acknowledged that she did not follow the hospital's policy when she did not return Patient 1's Advair Diskus medication to the medication room for safe storage.A telephone interview with the pulmonary department manager (PDM) was conducted on 9/7/12 at 10:20 A.M. The PDM acknowledged that RT 1 should have returned Patient 1's respiratory medications (Advair Diskus) to the medication room prior to administering Patient 2's breathing treatment. He stated that RT 1 should have followed the hospital's medication safety policy. A review of Patient 1's medical record was conducted on 9/27/12 at 8:00 A.M. Patient 1 was admitted to the hospital on 8/15/12 with a diagnosis that included congestive heart failure per the facesheet. According to Physician's Order dated 8/21/12 at 7:18 P.M., Advair 250/50 BID (twice a day) was to be administered to Patient 1.A review of the hospital's policy entitled "Drug Storage/Security," effective date of 6/12, was conducted on 9/27/12. The policy stipulated that, "Drugs shall be secured and accessible only to responsible personnel designated by the hospital. Per the same policy, it indicated that, "To decrease the opportunity for medication errors during medication administration it is recommended that the nurse remove medications for one patient at a time." An exit conference with the PDM and the Director of Critical Care was conducted on 9/28/12 at 4:10 P.M. They both acknowledged that the hospital's policy related to drug storage and security was not followed when RT 1 left Patient 1's Advair Diskus behind in another patient's room.
Outcome:
Deficiency cited by the California Department of Public Health: Pharmaceutical Service General Requirements