Department of Health Services Plans To Cite Martin Luther King Jr./Drew Medical Center for Medication Error
Department of Health Services officials on Wednesday told leaders at Los Angeles County-owned Martin Luther King Jr./Drew Medical Center that the agency plans to cite the facility for 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. DHS said it would cite King/Drew for "delaying care and services, failing to clarify medication errors and lacking 'general oversight' over pharmaceutical services," according to the Times (Ornstein, Los Angeles Times, 4/5). DHS' announcement follows the Board of Pharmacy's decision last week to cite the hospital for the same error, in which staff mistakenly administered Gleevec to a patient who was being treated for meningitis. According to the pharmacy board, King/Drew staff mistakenly entered a prescription for Gleevec into an electronic medical record for the patient. 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 for four days. 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 (California Healthline, 3/1). According to the Times, while medication errors at hospitals are "fairly common," county officials said that the incident at King/Drew was "more serious because it was not caught for several days" (Los Angeles Times, 3/5). The expected citations could jeopardize King/Drew's participation in Medicare and Medi-Cal, the AP/Fresno Bee reports (AP/Fresno Bee, 3/5).
King/Drew has been given a chance to respond to the citations before action is taken. Fred Leaf, chief operating officer of the Los Angeles County Department of Health Services, said that the fact that the error was not corrected for four days "signifies a little greater problem in terms of staff competence in the area of medication management." He added that the county DHS is deciding how to discipline the staff involved, saying, "Obviously, these nurses didn't know what the drug was and they didn't make an effort to know what the drug was, so they didn't follow their own nursing practice appropriately" (Los Angeles Times, 3/5). After the pharmacy board citation, the county began requiring two nurses to confirm the accuracy of physician orders for high-risk prescription drugs and pharmacists to ensure that printouts of patient medication records are reviewed by nurses and returned to the pharmacy with any required revisions. Physicians also must review patient medications daily (California Healthline, 3/1).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.