Two Patients Injected with Outdated Drug

By Walter F. Roche Jr.

Two patients at a rural Pennsylvania hospital were injected with outdated drugs on the same day despite a warning from another staffer that use of the outdated product could put patients at risk for infections or other adverse effects.
The report on the 70 bed Clarion Hospital in Western Pennsylvania also cites the facility for having outdated medicines and supplies in a crash cart in the hospital's cancer center and for having injections "administered by unqualified personnel."
The report followed a June 28 visit to the hospital which was described as an "unannounced onsite complaint investigation."
Clarion Hospital officials did not respond to a request for comment on the incidents which occurred in January. They did file a plan of correction with the state.
The state inspectors expressed concern that neither of the patients had been informed of the missteps.
"We cannot provide evidence that either patient was notified," the report states.
A patient, the report continues, should be notified that he received a potentially contaminated medication and education to be provided on monitoring for infection."
"When asked why patients had not been notified, Employee Three was unable to provide an answer," the report continues.
Surveyors also asked why the incident had not even been discussed by the hospital's patient safety committee. They were told,"We thought that it wasn't a serious event."
A review of hospital records showed the label on the vial of testosterone stated it was not to be used after Jan. 3, 2018.
The shots, the report states, were administered on Jan.10 and Jan. 24, more than 20 days after the vial should have been discarded.
Hospital records showed the injections were administered by a "medical assistant" despite a requirement for injections to be given by a registered nurse or practical nurse.
The hospital in its response said medical assistants would no longer be allowed to administer injections. In addition the staffer who gave the shots, despite the warning, is no longer employed at the hospital, the report states.
"The practice of medical assistants administering medications at hospital-based clinics was ceased during the survey on June 28, 2018," the plan of correction states.
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