SANTA CLARA VALLEY MEDICAL CENTER

Report ID: UMGJ11.02, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on interview and record review, hospital staff failed to safely dispense prescription medication for one of two sampled patients (2), when the prescription medication for Patient 1 was dispensed to Patient 2. The failure resulted in Patient 2 receiving incorrect medications. Findings:The California Department of Public Health received a faxed report on 3/27/14, which indicated, upon discharge on 3/21/14, Patient 2 was supposed to receive Seroquel (anti-psychotic medication), but was given Patient 1's Haldol (anti-psychotic medication), Ativan (anti-anxiety medication), and Inderal (anti-anxiety medication) instead. The hospital's internal investigation concluded a staff member had picked up the medications for Patients 1 and 2 to prepare both patients for discharge. When Patient 2 was discharged, he was inadvertently given Patient 1's medication. During an interview on 10/31/14 at 11:20 a.m., the compliance and privacy officer (CPO) stated the discharge medications for Patient 1 and Patient 2 were picked up from the pharmacy at 2:09 p.m. on 3/21/14. Patient 2 was discharged with Patient 1's Haldol 10 mg, Ativan 1 mg, and Inderal 20 mg, instead of his medication (Seroquel 300 mg). CPO stated the error was discovered approximately two hours later when Patient 1 was being discharged and the hospital staff realized Patient 2 had been discharged with Patient 1's medications. During an interview on 10/31/14 at 11:25 a.m., the director of nursing (DON) stated when Patient 2 was being discharged, the discharge nurse should have verified Patient 2's medications, compared them to the physician's orders, checked his identification band, and matched all of it with the physician's orders.During an interview on 11/20/14 at 2 p.m., registered nurse B (RN B) stated she discharged Patient 2 on 3/21/14 at approximately 3 p.m., and she had inadvertently given him the incorrect medication. RN B stated she was made aware of the error when the evening charge nurse had telephoned RN B asking if she had switched the medications. RN B further stated she did not compare the information on the medication bottle labels to Patient 2's identification when she discharged Patient 2.A review of a copy of a letter dated 3/27/14, from the hospital to Patient 1 indicated Patient 1's three medications were inadvertently given to Patient 2. A review of a copy of Patient 1's medication labels indicated the Patient was prescribed Haldol 10 mg, Ativan 1 mg, and Inderal 20 mg.A review of a copy of Patient 2's 3/21/14 "After Visit Summary" indicated the patient was prescribed Seroquel 300 mg tablet, take two tablets (600 mg total) by mouth at bedtime.A review of a copy of the hospital's 7/11/13 "Patient Identification (Verification)" policy indicated all employees must verify the identity of the patient before providing a patient with their discharge prescriptions. The identifiers stated and presented by the patient will be compared for accuracy to the same identifiers as found on the medication bottles.

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: UMGJ11.01

2 other violations reported on the same date. Note that other citations may be about the same event: Z32G11.01, Z32G11.02