King/Drew Is Again Assailed Over Prescription Drug Flaws

Government health inspectors plan to cite Martin Luther King Jr./Drew Medical Center for serious flaws in the way prescription drugs are managed at the public hospital in South Los Angeles.

The findings follow an investigation into an error last month in which the wrong patient received a potent anti-cancer drug for four days.

The California Department of Health Services this week told King/Drew hospital it would be cited for failing to administer medication accurately, delaying care and services for a patient, failing to clarify medication errors, and lacking “general oversight” over pharmaceutical services, according to a summary of the findings provided to Los Angeles County supervisors by the county health department.

The state hospital inspectors were the second group of regulators in a week to chastise the hospital for giving the anti-cancer medication Gleevec to a patient with meningitis.

Representatives from the California Board of Pharmacy cited the hospital for the error several days ago.

The state health department outlined its findings at a meeting with King/Drew leaders Wednesday night and will follow up with specific details in writing.

The expected citations would put the hospital at increased risk of losing federal funding for Medicare and Medi-Cal patients, but King/Drew would be given the chance to respond before any action was taken.

King/Drew, a 233-bed hospital in Willowbrook, just south of Watts, already faces the loss of federal funding because of unfavorable inspections in other areas.

In recent months, state and federal inspectors have cited the hospital for a pattern of lapses in care, including the deaths of five patients last year after a host of errors by nurses and other employees.

Medication errors are fairly common in hospitals, but county health officials said the latest mix-up at King/Drew Medical Center was more serious because it was not caught for several days.

“If you look at medication errors, generally you’ll see wrong dosages or missed medications, but usually it’s caught quicker and resolved,” said Fred Leaf, the county health department’s chief operating officer, who is leading a crisis management team at the hospital.

“This went on for four days,” Leaf said.

“That to me signifies a little greater problem in terms of staff competence in the area of medication management.”

Leaf said his agency was still weighing discipline for the employees involved.

“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,” Leaf said.

From now on, two King/Drew nurses must check to ensure the accuracy of orders for high-risk drugs and a nursing supervisor must review drug orders each shift.

Doctors are also being instructed to play a greater role in ensuring patients receive the right medications.