California Health Department investigation uncovered a medication storage problem at Kaiser Foundation Hospital South San Fransisco. The investigation began when two patients received pneumonia vaccines and then died from the disease. Their deaths were linked to improperly stored medication.
Bay Citizen reports a total of 14 hospitals were fined for practices “likely to cause serious injury or death to patients.” Kaiser Foundation Hospital South San Francisco was fined $50,000 for failing to follow the correct procedures for safely administering medications. At Kaiser, the majority of its medications were stored in one refrigerator. These drugs are meant to be kept at temperatures above freezing. The investigation uncovered that for a 32 month period, the refrigerator was set at freezing. While this may not seem like a huge difference, even small deviations in temperature can alter how effective a medication is. Ultimately, the hospital gave potentially bad drugs to almost 4,000 patients.
Kaiser found the cause of the error and reported it to the Health Department. In addition to engineering mistakenly scheduling maintenance every three years instead of every three months, there was no staff member responsible for monitoring the refrigerator.
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The hospital contacted patients who were deemed at high risk for a bad drug reaction, but did not contact everyone who had received the medicines. After criticism from the Department of Public Health, all of the patients were contacted. But when some returned for revaccination, they were given the wrong medicine and were only vaccinated against tetanus and diptheria, but not pertussis.
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