Scripps Mercy Hospital

Report ID: 1OPP11.04, California Department of Public Health

Reported Entity: SCRIPPS MERCY HOSPITAL

Issue:

Based on interview and record review, the hospital failed to ensure that pharmacy staff implemented it's policy pertaining to medication security and storage, for 1 of 2 sampled patients (Patient 1). The pharmacy technician (PT 1) inadvertently gave technical partner (TP 1) Patient 1's bag of home medications instead of the Patient 2's home medications (intended recipient).Findings:A review of Patient 1's medical record was conducted on 10/18/12 at 8:15 A.M. Patient 1 was admitted to the hospital on 6/1/12, with a chief complaint of abdominal redness and swelling per the Discharge Summary, dated 6/3/12. Per the Discharge Summary, Patient 1 was discharged on 6/3/12.According to Patient 1's "Patient's Own Medications Envelope" (an inventory of the patient's home medications at admission), dated 6/1/12, the following medications were listed: Insulin (medication to treat high blood sugars) syringe, hydrocodone (used to treat moderate to severe pain), hydromorphone (also known as Dilaudid - a narcotic used to treat moderate to severe pain), Oxycodone (a narcotic pain reliever, used to treat severe pain), Quinapril (blood pressure medication), methotrexate (used to slow the growth of certain cells in the body), ketoprofren (nonsteroidal anti-inflammatory drug), Ferrous Sulfate (iron used to treat anemia), Citalopram (anti-depressant medication), Furosemide (used to treat edema), Folic Acid (vitamin supplement), multi-vitamins, Amiodarone (medication used for irregular heart beat), Bayer Aspirin (relieves pain and reduces fever), Vitamin D3, Prevacid (antacid- suppresses acid secretion in the stomach) and Prilosec (antacid). Per the same form, a note from pharmacy staff indicated that on 6/3/12, Patient 1's narcotics were given to a licensed staff on the 6th Floor.A review of Patient 2's medical record was conducted on 10/18/12 at 8:15 A.M. Patient 2 was admitted to the hospital on 5/31/12, with a chief complaint of respiratory distress per the Discharge Summary, dated 6/2/12. Per the Discharge Summary, Patient 2 was discharged on 6/2/12.A review of the hospital's policy entitled "Medications: Orders, Administration, and Documentation," effective date of 2/2012, was conducted. The policy indicated patient's own medications will be inventoried on the "Patient's Own Medication Envelope" and returned to the patient at the time of discharge. Per the same policy, it stipulated that "Medications are safely and securely stored throughout the hospital."On 11/8/12 at 9:25 A.M., a telephone interview with the Clinical Risk Specialist (CRS) was conducted. A request was made to interview PT 1. CRS stated that PT 1 no longer worked at the hospital.An interview and joint record review with technical partner (TP 1) was conducted on 11/8/12 at 3:10 P.M. TP 1 stated that she assisted with the discharge of Patient 2. She stated that she picked up Patient 2's home medications from the pharmacy on 6/2/12, but did not verify that the home medications given to her by PT 1 belonged to Patient 2. She acknowledged that she signed the hospital's form entitled "Patient's Own Medications Envelope" for Patient 2 as requested by PT 1. She explained that the hospital's process was to sign the form after the home medications were presented before the staff and verified by both staff members present. She acknowledged that she did not follow the hospital's policy pertaining to medication security and storage. She stated that she returned to the 6th Floor and reported to Registered Nurse (RN 1) that she had Patient 2's home medications from the pharmacy. She stated that RN 1 had told her that Patient 2 was ready for discharge and she handed the bag of home medications (belonging to Patient 1) to Patient 2. An interview with the Pharmacy Manager (PM 1) was conducted on 11/20/12 at 2:50 P.M. PM 1 confirmed that PT 1 was no longer an employee of the hospital however, she stated that she had spoken to PT 1 about what had happened with Patient 1's and Patient 2's home medications on 6/2/12. She stated that PT 1 acknowledged that within his practice, he usually double-checked to ensure that the correct home medications were released to the correct recipient. She stated that PT 1 stated that he was very busy that day and did not follow the hospital's process pertaining to medication security and storage. PM 1 acknowledged that PT 1 should have followed the hospital's policy. As a result, she agreed that Patient 1's home medications were given to the wrong patient (Patient 2) on 6/2/12.

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 3 other violations. Note that these may be related to the same event: 1OPP11.01, 1OPP11.02, 1OPP11.03

1 other violation reported on the same date. Note that other citations may be about the same event: GZZK11.01