SOUTHERN COMPLIANCE COMMITTEE
June 15, 1999 Page 9 Of 23
Karl Jacobs, PIC CI 97 15818
RPH 26856
Tami Michelle Cope
RPH 46413
Kaiser Hospital Pharmacy
San Diego, CA

HSP 36813

Giovanni S, Miano, Pharmacy Services Director
Bruce Cromer, Pharmacy Supervisor
Richard D. Levy, In Patient Pharmacy Director
Anthony A. Barrueta, Counsel

Karl Jacobs and Tami Michelle Cope appeared before the Southern Compliance Committee
as the result of an investigation that revealed that Kaiser Hospital Pharmacy incorrectly filled
narcotic requisitions, and pharmacy staff did not follow the pharmacy’s policy and procedures.
On February 8, 1999, a violation notice was issued to RPH Jacobs, RPH Cope, and
Kaiser Hospital Pharmacy for violation of:

· Business and Professions Code section 4301 – Unprofessional conduct.

· California Code of Regulations section 22CCR 70263 (c) – Required policy and procedure
manual.

· California Code of Regulations section 1718 – Current inventory defined.

· Business and Professions Code section 4081 – Records of dangerous drugs and devices kept
open for inspection; maintenance of records and current inventory.

Board Member Steve Litsey recused himself from this appearance.

RPH Cope explained that she had recently transferred from the oncology pharmacy to the
inpatient pharmacy. Going into the narcotic vault was a new procedure for her. RPH Cope
stressed that she is a very careful pharmacist, and has done many good things for her patients. It
is unfortunate that the error was not caught while she was calling the drugs off to the nurse that
was receiving the medication. RPH Cope explained that the medication was placed on the wrong
shelf in the supply room. The containers from the manufacturer are the same, and the dosage is
the same. RPH Cope added that she was written up and received three days suspension for this
violation.

RPH Cope continued stating that after the error was made; her first reaction was
prevention of future errors. She photocopied both of the manufacturer's containers and
distributed a warning to all pharmacy staff to be alert and double check when dealing with these
medications. These warnings were also sent to all nursing stations. 

RPH Jacobs stated that prior to the date of the incident he had left the pharmacy. He has
been out on a medical leave of absence. 

The committee asked those present if RPH Jacobs was on medical leave, why was he still
listed as pharmacist in charge. 

Mr. Miano responded that RPH Jacobs had just left the pharmacy on medical leave, and
an interim pharmacist in charge had not been chosen.
The committee asked those present when are the drugs dispensed from the narcotic vault
subtracted from inventory. 

RPH Cope responded that an inventory control clerk performs that function on Monday
morning. She added that the drugs had been administrated to the patients over the weekend.
The committee provided those present with a copy of the Institute for Safe medication
Practice (ISP) newsletter. The committee requested that the management provide the
information to all pharmacy staff, and require that they read it. 

Mr. Miano responded that they would comply. 

The committee admonished those present, that this incident is a system problem. The
committee recommended that the management develop a better system where the medications
are logged out as soon as they are removed from the narcotics vault, rather than waiting until
Monday. The committee also suggested that the management take a look at how many narcotics
are being used in the hospital on weekends, so that there are not so many emergency requests on
the weekends.

SOUTHERN COMPLIANCE COMMITTEE
June 15, 1999 Page 10 Of 23
M/S/C: Strom/Zia
The committee accepted the appearance of Karl Jacobs, Tami Michelle Cope, and Kaiser
Hospital Pharmacy; (a) the matter will be made a part of the record of Karl Jacobs, RPH 26856,
Tami Michelle Cope, RPH 46413, and Kaiser Hospital Pharmacy, HSP 36813; (b) Send out the
information from the ISP News letter to all pharmacy staff. (c) Have a staff meeting, and send a
copy of the minutes from the meeting to the Board of Pharmacy. (d) Report within 60 days the
results of the staffing evaluation. (e) Submit an article to the Board of Pharmacy for the
newsletter on this incident. No further action will be taken at this time.