Kaiser hospital fined for med storage error

The California Department of Health has fined Kaiser Permanente South San Francisco Medical Center $50,000 for failing to follow "policies and procedures for the safe and effective administration of medication," in relation to improper refrigeration. Thousands of patients received the potentially dangerous medications over almost three years.

The Department of Health's investigation linked the error to the deaths of two patients. According to the investigation, the hospital stored most medications needing refrigeration in one refrigerator in its pharmacy. The medications were supposed to be kept above freezing, but the refrigerator was set at freezing for a 32-month period between 2006 and 2009, investigators found.

The hospital stored 78 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 improperly stored drugs were administered to nearly 4,000 patients, according to the investigation.

The hospital discovered the cause of the error was that an engineer mistakenly had scheduled preventive maintenance checks on the refrigerator for every three years instead of every three months, and the hospital's pharmacy director told investigators that no staff member had been "responsible for monitoring refrigerator temperatures."

A spokesman for Kaiser did not reply to Healthcare Risk Management's request for comment but provided a statement from Frank Beirne, senior vice president and area manager for Kaiser Permanente South San Francisco Medical Center. "We immediately corrected the equipment problem and took steps to make sure it would not happen again," Beirne said in a statement.

Once the problem was discovered, the hospital reported it to the state, and it contacted some patients who had received the vaccines and tuberculosis tests — only those that hospital officials thought 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," according to Beirne's statement.

That step was not sufficient for the Department of Public Health. It's investigation chided the hospital for failing to notify all the patients who had received the vaccines and tests. The hospital failed to contact some patients who had received a compromised dose of the pneumococcal vaccine, which is used to prevent pneumonia. The investigators noted that two patients who had received compromised doses later died after contracting pneumonia, and one of them had never been notified of the need 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.

The Department of Health instructed the hospital to notify all the patients who had been affected and still were living, and the hospital complied. The full investigative report can be found online at http://tinyurl.com/6pqe7vr.