California found 'major deficiencies' at hospital pharmacy on probation
Sutter Coast Hospital's compounding pharmacy placed on a three-year probation
Sutter Health

In 2019, Sutter Coast Hospital's compounding pharmacy in Crescent City, California, came under scrutiny by the California State Board of Pharmacy, resulting in a recent imposition of a three-year probation. This development followed a routine inspection conducted in January 2019, during which a board investigator identified what were described as "major deficiencies" concerning staff training and knowledge in the field of compounding pharmaceuticals.

The investigation brought to light a range of concerns related to the training of pharmacy personnel. It was discovered that the pharmacist in charge, along with her team, had not completed the necessary training required prior to engaging in compounding activities. These deficiencies extended to critical areas such as aseptic hand washing, garbing, proper cleaning of controlled environments, and the accurate documentation of drug compounds. Inspectors were particularly alarmed by the lack of knowledge demonstrated by employees in these fundamental regulatory aspects.

Another noteworthy issue that came to light was the inadequacy of the facilities themselves. In accordance with pharmacy law, a sink with running water is required within the "parenteral solution compounding area or adjacent to it." However, the sole sink available was located in a restroom, falling short of these legal requirements. Furthermore, the inspectors observed staff members failing to adhere to appropriate clothing standards and noted unsanitary conditions within the pharmacy.

As a consequence of these findings, Sutter Coast Hospital's compounding facility was placed on probation starting from July 23. This disciplinary action imposes certain obligations on the hospital, including unannounced visits by the pharmacy board and quarterly reporting to the state. Additionally, the hospital is required to provide five hours of compounding education for pharmacy technicians and pay an undisclosed fine as part of the probationary measures.

It is worth noting that subsequent to the inspection, the pharmacy has worked closely with the California Board of Pharmacy to address and rectify the violations identified. A spokesperson for Sutter Health, based in Sacramento, expressed their commitment to the highest standards of patient care and community health.

"We have partnered with the California Board of Pharmacy and have made significant investments at Sutter Coast's compounding facility," the spokesperson stated. "These recent upgrades exceed all sterile compounding standards for hazardous drugs, which provide protections for employees and patients. Sutter Health remains committed to providing our patients excellent and quality care and supporting overall community health."

In light of these corrective measures and the hospital's commitment to compliance, it is anticipated that the probation period will serve as an opportunity for Sutter Coast Hospital to enhance its compounding pharmacy operations and ensure the highest level of safety and quality in pharmaceutical compounding.