King/Drew Cited for Giving Wrong Drug

The California Board of Pharmacy has cited Martin Luther King Jr./Drew Medical Center for giving a potent anti-cancer medication to the wrong patient last week, Los Angeles County health officials said Friday.

Pharmacy inspectors visited the county-owned hospital after The Times reported that employees at King/Drew had improperly given the drug Gleevec to William Watson, 46, an uninsured patient with meningitis.

The pharmacy board found that a Gleevec order intended for another patient had been erroneously entered in Watson’s computerized medication record in King/Drew’s pharmacy on Feb. 11, said John Wallace, a Los Angeles County health department spokesman.

Wallace did not identify Watson by name, but Watson confirmed he was the patient.

On Feb. 12 and 13, nurses caught the mistake by comparing pharmacy records with physician orders. They did not give the medication to Watson, but for some reason the erroneous order was not removed from the computer.

Over the next four days, different nurses gave the man four doses of the drug, the pharmacy board found.

When Gleevec did not appear in the medication record of the patient who was supposed to receive it, a nurse alerted the pharmacy, which created a second order for that patient but did not investigate further.

The county health department has 14 days to respond to the pharmacy board and detail how it plans to prevent the mistake from happening again. At that point, the board will decide what, if any, penalty to impose, Wallace said.

As is their standard practice, pharmacy board officials declined to comment and would not confirm that they had visited the hospital.

King/Drew was already under close scrutiny by state and federal inspectors because of a pattern of lapses in care, including the deaths of five patients last year after a host of errors by nurses and other employees.

Fred Leaf, the county health department’s chief operating officer, said his agency had taken several corrective actions as a result of the pharmaceutical error.

From now on, two nurses must check to ensure the accuracy of orders for high-risk drugs. And pharmacists will be responsible for ensuring that printouts of patients’ medication records are reviewed by nurses and returned to the pharmacy, with any changes noted.

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Times staff writer Tracy Weber contributed to this report.