SANTA CLARA VALLEY MEDICAL CENTER

Report ID: EGUY11.05, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to distribute the correct medication to one of two sampled patients (1), when the hospital affiliated pharmacy (HAP) gave Patient 2 medications which belonged to Patient 1. The failure resulted in Patient 2 receiving and taking the incorrect medication. Findings:During an interview on 6/24/14 at 11 a.m., the pharmacy assistant director (PAD) stated Patient 2 went to the HAP to check if the HAP staff had received her doctor's faxed prescription order. When Patient 2 arrived at the "drop-off" window, she had been issued a patient's claim check. A hospital staff attached the other half of the claim check to the wrong prescription fax. Patient 2 went to the pick-up window with her claim check and was handed the prescription which corresponded to the number on the claim check. PAD then stated, at a later time, Patient 1 came to HAP to pick-up his prescriptions. During this time, the HAP staff realized Patient 1's medications were given to the wrong patient (Patient 2). When Patient 2 returned to the HAP, with the wrong medications, it was discovered who had received Patient 1's medications. During a telephone interview on 6/24/14 at 12:15 p.m., PT stated he gave Patient 2 her medication prescription based on the claim check number, and not her identity. PT stated the name on the claim check was of Asian descent, and so was Patient 2, therefore did not ask Patient 2 for another form of ID. PT further stated, "It was my fault, I should have asked for another ID."A review of a copy of a letter dated 6/25/14 from the hospital to Patient 1 indicated, HAP's staff at the pick up window gave another patient (Patient 2) the prescription medication that belonged to Patient 1.During an interview on 6/24/14 at 10 a.m., the ECO stated Patient 2 took one pill from each of the two medications which belonged to Patient 1.During an interview on 6/24/14 at 11:05 a.m., PAD stated Patient 2 took one pill from each of the two medications which belonged to Patient 1. A review of the hospital's 11/16/10 "Patient Identification (Verification)" policy indicated, all employees must verify the identity of the patient prior to the administration of medication... at least 2 of the 3 acceptable patient identifiers. The identifiers stated and presented by the patient will be compared for accuracy.

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 4 other violations. Note that these may be related to the same event: EGUY11.01, EGUY11.02, EGUY11.03, EGUY11.04

3 other violations reported on the same date. Note that other citations may be about the same event: CRM711.01, CRM711.02, ITGS11.01