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DEPARTMENT OF CONSUMER AFFAIRS
BOARD OF PHARMACY
SOUTHERN COMPLIANCE
COMMITTEE MEETING
MINUTES
Case #CI 97 15818
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. Back to kaiserpapers.com/fines