Medication Storage Error Affects Thousands of Kaiser Patients

Two patients who had received compromised pneumonia vaccines later died from the illness

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By Katharine Mieszkowski

Source: The Bay Citizen (http://s.tt/14J6t)

Medication Storage Error Affects Thousands of Kaiser PatientsTwo patients who had received compromised pneumonia vaccines later died from the illness

By Katharine Mieszkowski

This has been mirrored here for historical purposes from:http://www.baycitizen.org/health/story/medication-storage-error-affects-kaiser/

For nearly three years, thousands of patients at Kaiser Foundation Hospital South San Francisco received vaccines and medications that had been improperly refrigerated, potentially compromising the medicines' potency, according to a California Department of Health investigation. See: http://www.cdph.ca.gov/certlic/facilities/Documents/HospitalAdministrativePenalties-2567Forms-LNC/2567-KaiserSouthSanFrancisco-XMV011-SF.pdf

The investigation linked the error to the deaths of two patients.

On Thursday, the department fined the hospital $50,000 for failing to follow “policies and procedures for the safe and effective administration of medication.” Thirteen other hospitals around the state also received penalties Thursday for practices “likely to cause serious injury or death to patients,” including four in the Bay Area: San Francisco General Hospital, UCSF Medical Center, Sutter-Solano Medical Center and Lucile Packard Children's Hospital.

The error at Kaiser's South San Francisco hospital affected the most patients in the Bay Area.

The hospital stored the majority of its medications that needed to be kept cool in one refrigerator in its pharmacy. For a 32-month period between 2006 and 2009, the temperature inside the refrigerator was set at freezing, even though the medicines needed to be kept above freezing, investigators found.

There were 78 different types of medications in the refrigerator, including vaccines used to prevent such diseases as Hepatitis B, tetanus and pneumonia; skin tests; and insulin used to treat diabetes. The drugs were administered to nearly 4,000 patients, according to the investigation.

The hospital discovered the cause of the error and reported it to the state: an engineer had mistakenly scheduled preventive maintenance checks on the refrigerator for every three years, instead of every three months.

The hospital’s pharmacy director acknowledged that no staff member had been “responsible for monitoring refrigerator temperatures,” according to the investigation.

“We immediately corrected the equipment problem and took steps to make sure it would not happen again,” Frank Beirne, senior vice president and area manager for Kaiser Foundation Hospital South San Francisco, said in a statement.

The hospital contacted patients who had received the compromised doses of vaccines and tuberculosis tests and whom it deemed needed to be revaccinated or retested. "Our physicians worked with their patients to determine if any additional actions may have been needed, and if warranted, patients received re-vaccinations or retests at no charge," Beirne said in a statement.

But the Department of Public Health criticized the hospital for initially failing to notify all the patients who had received the vaccines and tests. The hospital only contacted those patients it deemed at high risk, the state said.

It failed to contact some patients who had received a compromised dose of the pneumococcal vaccine, which is used to prevent pneumonia. The vaccine may undergo an “irreversible loss of potency with exposure to freezing temperatures,” according to the Centers for Disease Control and Prevention.

Two patients, both in their 80s, who had received compromised doses later died after contracting pneumonia. The state found that the hospital never notified one of those patients to be re-vaccinated. The hospital also failed to contact two other patients who received compromised doses of the vaccine and who later contracted pneumonia, according to the investigation.

After being prompted by the state, the hospital contacted all the patients who had been affected and were still living.

Some patients who had received compromised doses of a vaccine for tetanus, diphtheria and pertussis were given the wrong shot when they returned to the hospital to be revaccinated. They received the a vaccine that only protected against tetanus and diphtheria, health officials found.

The Lucile Packard Children’s Hospital at Stanford faces a fine of $50,000 for a medication error involving a newborn in 2010. Hospital officials said in a statement that they'd received notification of the fine Thursday and "are reviewing the basis for the fine and determining next steps."

The state fined San Francisco General Hospital $50,000 for a 2009 error. Surgeons performed a partial mastectomy on a cancer patient who was supposed to receive a total mastectomy of that breast. After the error, the patient sought care at another hospital, resulting in a delay in her treatment.

"No one would want this to happen to them or their loved one, and we take it very seriously," Sue Currin, CEO of San Francisco General Hospital, said in a statement.

Sutter Solano Medical Center faces a $50,000 fine for an error made in 2009. A woman had to undergo a second surgery after physicians left a surgical sponge in her abdomen following a caesarean section. The hospital has since implemented a computer-assisted bar coding system to keep track of the sponges, according to Sy Neilson, a spokesman for the hospital.

UCSF Medical Center is facing a $75,000 penalty — its sixth since 2007 — for a surgical error in 2009. A surgeon began operating on a patient's eye, before realizing the procedure needed to be performed on the other eye. The doctor then completed the surgery on the correct eye. The hospital is still considering whether it will pay the fine or appeal the penalty, officials said.

Since 2007, when the state began fining medical centers for errors that jeopardize patients health and safety, it has assessed 214 penalties against 123 hospitals, according to Pam Dickfoss, acting deputy director of the Center for Health Care Quality at the California Department of Public Health.

The state previously announced penalties against hospitals in June and September of this year.

The investigation linked the error to the deaths of two patients.

The error at Kaiser's South San Francisco hospital affected the most patients in the Bay Area.

The hospital’s pharmacy director acknowledged that no staff member had been “responsible for monitoring refrigerator temperatures,” according to the investigation.

Source: The Bay Citizen (http://s.tt/14J6t)For nearly three years, thousands of patients at Kaiser Foundation Hospital South San Francisco received vaccines and medications that had been improperly refrigerated, potentially compromising the medicines' potency, according to a California Department of Health investigation.

The investigation linked the error to the deaths of two patients.

The error at Kaiser's South San Francisco hospital affected the most patients in the Bay Area.

The hospital’s pharmacy director acknowledged that no staff member had been “responsible for monitoring refrigerator temperatures,” according to the investigation.

Source: The Bay Citizen (http://s.tt/14J6t)

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