Board of Pharmacy Cites Martin Luther King Jr./Drew Medical Center for Medication Error
The Board of Pharmacy has cited Los Angeles County-owned Martin Luther King Jr./Drew Medical Center over an incident in which the hospital mistakenly administered the cancer medication Gleevec to a patient without cancer over a period of four days last month, the Los Angeles Times reports. Pharmacy board officials visited the hospital after the Times reported that staff at King/Drew had mistakenly administered Gleevec to William Watson, an uninsured patient with meningitis (Ornstein, Los Angeles Times, 2/28). The latest incident at King/Drew follows the release of a CMS report in January that found staff errors led to the deaths of five patients at the hospital in 2003. According to the report, the patient deaths and performances of staff indicated the "failure of the hospital to ensure quality health care in a safe environment" (California Healthline, 2/27). A county review of the latest incident found that "the systems designed to protect patients had broken down and individual employees had not performed their duties properly," the Times reports (Ornstein/Weber, Los Angeles Times, 2/26). According to the pharmacy board, King/Drew staff mistakenly entered a prescription for Gleevec into a computerized medical record for Watson. Nurses found the error on Feb. 12 and 13 after they compared pharmacy records and physician orders but did not remove the prescription from his medical record. Over the next four days, different nurses mistakenly administered Gleevec to Watson (Los Angeles Times, 2/28). According to Watson, a nursing supervisor later asked him to sign a form that said the error had occurred but "had no effect" on him. County officials planned to decide late last week whether to discipline King/Drew staff involved in the incident (Los Angeles Times, 2/26).
Fred Leaf, chief operating officer of the county Department of Health Services, said that the county has taken several corrective actions as a result of the incident: two nurses must confirm the accuracy of physician orders for high-risk prescription drugs, and pharmacists must ensure that printouts of patient medication records are reviewed by nurses and returned to the pharmacy with any required revisions (Los Angeles Times, 2/28). Physicians also must review patient medications daily. The Department of Health Services last week was informed of the incident but has not taken action against King/Drew (Los Angeles Times, 2/26). The pharmacy board said that the county health department has 14 days to outline a plan to prevent similar incidents in the future. At that time, the pharmacy board will decide whether to take action against King/Drew, according to John Wallace, a county health department spokesperson (Los Angeles Times, 2/28).
"Obviously something like this is terrible. But you can believe, you can bet, that every time something occurs, the safety process doubles. ... I think we're doing everything we can to assure there's a safe environment," Leaf said. Supervisor Gloria Molina said of staff members at King/Drew, "They're just not prepared to meet the mission out there, and they're going to have to move out of the way." Supervisor Zev Yaroslavsky said, "You can't argue that this is an anomaly. It appears to be more normal than an anomaly." Supervisor Yvonne Brathwaite Burke said, "I don't know that you can correct all of the problems from 25 years in three months" (Los Angeles Times, 2/26).
"The Watson incident was hardly the first time a patient's life has been in jeopardy because they sought treatment at King/Drew," and the hospital "continues to put patients' lives at risk, even as it is seemingly trying to clean up its problems," according to a Long Beach Press-Telegram editorial. The editorial states that "we're starting to wonder whether shutting the doors of the hospital wouldn't be such a bad idea," adding, "That way, at least, it couldn't kill any more patients." The editorial concludes, "If King/Drew is to succeed in its reforms, William Watson must be the last" (Long Beach Press-Telegram, 2/26).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.