After a three-day investigation in September, CMS found problems in the pharmacy that included missing medication labels, unsystematic labeling of medication and incompetence among the staff.
The report details several instances of patients’ safety being jeopardized, including one in which a patient went into anaphylactic shock after an incorrectly filled medication was administered. A nurse told CMS regulators that the medication had been pulled from the automated dispensing system under an erroneous name several times. Another time, the pharmacy delivered morphine at a dosage five times greater than the physician prescribed.
Several staff members said they feared retaliation if they reported concerns to the hospital administration. Four physicians told CMS that they told hospital administrators that the pharmacists lacked experience and medication errors were on the rise.
The CMS survey follows reports of 45 medication errors that were reported at the hospital in July and August.
Dillingham-based Bristol Bay Area Health Corp., which owns the hospital, said it has submitted a plan of correction to CMS. Under the plan, the provider will train new staff and update procedures.
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