Friday, February 10, 2012

Kern County: Grand jury highlights medicine errors at children's shelter

BY JAMES BURGER Californian staff writer | Thursday, Feb 09 2012

The Kern County Grand Jury this week called for sharp changes in how staff at the A. Miriam Jamison Children's Center deliver over-the-counter and prescription medications to juveniles sheltered there.

The report shed light on a string of "medication error" incidents in which staff gave children the wrong doses or gave drugs to the wrong children.

Grand jurors called for Department of Human Services Director Pat Cheadle to staff a registered nurse from Kern Medical Center at the emergency shelter 24 hours a day, saying the county was violating state regulations and an agreement with KMC by having Jamison staff "dispense" drugs to children.

But both Cheadle and Kern Medical Center CEO Paul Hensler said Thursday that the jury's understanding of regulations and findings in the report were mistaken.

"They're confused," Hensler said.


Cheadle said that in February 2011, her office learned that group counselors had at times made mistakes when giving medication to children -- either accidentally overdosing kids, failing to give them enough medicine or giving medications to the wrong children.

No children were seriously injured, she said.

Those mistakes, Cheadle said, hadn't been reported to top shelter managers or people in her office. Staff members involved in the incidents were never disciplined as news of the incidents never made it out of the Jamison Center.

Finally, in February 2011, news of a "medication error" did make it to her office, Cheadle said. Her office moved to investigate and correct the situation.

"Our policy for the group counselors to give medication had to be strengthened," she said. "Training needed to be updated and strengthened."

The employee was placed on administrative leave, she said, during the inquiry. Group counselors reacted strongly, Cheadle said.

"It would be fair to say that some of the staff became concerned about the security of their job should a medication error have occurred," Cheadle said.

Some employees refused to administer drugs, she said. The Service Employees' International Union sent a letter to Cheadle claiming that registered nurses are required by law to dole out drugs to children at Jamison.

SEIU officials knowledgeable about the situation were not immediately available for comment Thursday.


Cheadle said that since February 2011, there have been four or five other incidents where "medical errors" have happened.

None resulted in serious injury, she said, though two times children were transported to Kern Medical Center to be checked out.

All the incidents have been investigated.

"We have not taken disciplinary actions on anyone as a result of those actions," Cheadle said. "There has been no gross negligence. There has been no harm to the child."

But the situation, and the debate over the role of nurses at Jamison, came to the attention of the grand jury.

"Somehow the grand jury became aware of the situation and came in and started to interview staff and management, which led to this report," Cheadle said.

The grand jury report indicates that group counselors at Jamison are not allowed to give medication to juveniles, quoting the memorandum of understanding under which Kern Medical Center sends nurses to the shelter to oversee medical care of children.

The grand jury committee that investigated the situation, the report states, "relied heavily upon the KMC/(Jamison) Center MOU which clearly specifies that medications are to be dispensed only by KMC medical staff to be in compliance with the California Nursing Practice Act."

But Hensler said the grand jurors have gotten confused about the medical definition of the word "dispense."

And both he and Cheadle said the Nursing Practice Act does not apply to staff at the Jamison Center, who are not nurses.

It's true that licensed medical staff are the only ones allowed to "dispense" or "administer" drugs, Hensler said. But under the law, dispensing a drug is what a pharmacist does -- counting, compounding, packaging and labeling the drug.

"Administration" of a drug is defined by state regulations as giving a patient a single dose of medication from a bulk supply of that medication.

That is, Cheadle said, not what the group counselors are required to do.

What they do is "deliver" medications to the children, taking drugs from a properly labeled, physician-approved prescription container and following the directions on the container to give the child the proper amount of that drug, she said.

It is no different, Cheadle said, from what parents do when their children are given a prescription by a doctor. And, she said, it is completely within the powers of a group counselor at Jamison to perform that task.


The grand jury report also recommends that communication between Kern Medical Center staff and Jamison staff and management be strengthened.

And it encourages the Department of Human Services to explore 24-hour medical staff coverage at Jamison Center.

Hensler discounted the need for 24-hour service at Jamison, saying group counselors are capable of "delivering" drugs to children.

Currently, medical staffing at Jamison costs the Department of Human Services $100,000 a year, he said.

Expanding that coverage would quintuple that expense.

"Do you need an RN on staff 24 hours a day?" he said. "If it's just for the delivery of the medications, obviously we don't think so."

Still, the Human Services Department is required to officially respond to the grand jury report within 90 days.

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