CMS Report Cites Repeated Medication Errors at King/Drew Medical Center

Martin Luther King Jr./Drew Medical Center staff "repeatedly withheld medications from patients and administered the wrong drugs or dosages," according to a CMS report released Tuesday, the Los Angeles Times reports. CMS inspectors, who were sent to investigate King/Drew this month after a meningitis patient who did not have cancer was mistakenly administered a cancer treatment for four days, found that the patient was affected by more than 40 other medical errors. According to the report, investigators also found errors in medication administration to 11 other patients. Inspectors found that the "mistakes had been happening for some time -- at least according to nurses," the Times reports. The report said that although nurses fax orders for drugs "over and over again," the medications do not arrive from the hospital pharmacy. "If the medication is not delivered and nursing does not send someone to get it, 'the medication is not given,'" the report said, summarizing nurses concerns. The investigation pointed to a wide range of problems, including:

• The meningitis patient whose case triggered the investigation also did not receive 25 doses of drugs ordered by doctors and was given 12 extra doses of drugs and one anti-psychotic injection not ordered by anyone;
  
  
• An ovarian cancer patient with respiratory failure was given an improper dosage of antibiotics, did not receive an ordered dose of blood thinner and only received three of 12 doses of ordered respiratory drugs;
  
  
• A stroke patient waited almost five hours for a prescription drug to prevent heart attacks and another stroke, which pharmacists declined to fill because a doctor had misspelled the drug's name;
  
  
• An inspector located a missing dose of intravenous antibiotics for a tuberculosis patient on the pharmacy counter with the label, "missing dose." Inspectors also noted errors in three of six medications that the same patient received over five days; and
  
  
• A paraplegic with a bone infection waited for a laxative suppository ordered by a physician for at least five days. In the same case, nurses and pharmacists did not follow orders for other medications, including milk of magnesia, zinc oxide, vitamin C and antibiotics.

Dr. Robert Wachter, chief of medical services at the University of California-San Francisco, said, "It's scary. This is a cautionary tale of what happens when everything falls apart." Katherine Knapp, director of the Center for Pharmacy Practice Research and Development at Western University of Health Sciences in Pomona, asked, "How could the hospital be accredited and have these systems operating so poorly?" Fred Leaf, chief operating officer of the Los Angeles County Department of Health Services, said that caregivers at the hospital "responded inappropriately and certainly didn't behave as if they recognized the gravity of the situation." Leaf said of pharmacists' who declined to fill necessary prescriptions, "That is intolerable, unacceptable and something that is, to me, unexplainable." Amy Gutierrez, King/Drew's pharmacy director, said the crisis team at the hospital was "prompt[ing] action," adding, "There is a culture within King/Drew Medical Center of new accountability toward patient care," the Times reports (Ornstein/Hymon, Los Angeles Times, 3/17).