The California Department of Public Health (CDPH) announced on Thursday that it will fine Emanuel Medical Center of Turlock $50,000 in administrative penalties after the hospital failed to follow policies and procedures for the safe distribution and administration of medication.
The penalty was the result of an investigation into Emanuel Medical Center’s Medication Error Reduction Plan, specifically for the distribution of the anti-nausea medication Droperidol. CDPH found that one Emanuel physician did not follow the hospital’s established procedure for dispensing the medication to at least five patients.
Droperidol has an FDA black box warning that the drug can cause heart rhythm disturbances at or below recommended doses. The label says that these symptoms have appeared even in patients with no known risk factors. Because of this risk, Emanuel Medical Center has established procedures that every patient must be given a 12-lead electrocardiogram (EKG) before the pharmacy will dispense Droperidol. The procedure also states that Droperidol should not be dispensed to patients with certain EKG results.
Medical records of 61 patients who received Droperidol were collected and 12 random records were reviewed. Of these 12 patients, the CDPH report found that five did not meet the hospital’s required procedures for prescribing Droperidol, but were given the drug anyway.
“This is an isolated incident with one particular physician that did not follow documentation procedures,” said Emanuel Medical Center CEO John Sigsbury.
This was the first administrative fine levied against Emanuel Medical Center. Sigsbury said that the hospital, not the physician, is responsible for paying the fine. He said that the fine was a result of the physician’s lack of documentation. He called Droperidol a medication that anesthesiologists are familiar with and trained to work with.
“No harm at all came to any patients related to this,” Sigsbury said.
The prescribing physician did not document his use of Droperidol for any of the five patients, but the drug appeared on their charge sheet and medication administration record summaries. According to the CDPH, the physician said in an interview that he used the drug at the beginning of surgery and forgot to document its use.
As a result of the administrative fine, Emanuel Medical Center has removed Droperidol from its pharmacy and the hospital will no longer administer the drug.
“We know that this incident will never reoccur at this hospital,” Sigsbury said.
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