Heparin still shows up

The Daily Journal continues its fine work on tainted heparin ending up in hospitals all over California (and linked to more than 90 deaths). In today's story (no link available), Evan George reports that hundreds of patients are still receiving the anti-clotting drug, months after the recall alerts went out. Documents show that UC San Francisco Medical Center and Children's Hospital of Central California in Madera accidentally used heparin on newborns, and Vista Specialty Hospital in San Gabriel purchased the drug after the recall in February.

The records show that during April and May the blood-thinner, which has been linked to more than 90 deaths, actually reached hospitalized patients - a more serious breach of patient safety than was previously reported. Regulators with the Board of Pharmacy said in August that they were moving to fine 94 hospitals and their head pharmacists just for keeping tainted heparin on the shelf. At least 16 hospitals could face $25,000 penalties for injecting patients with the recalled drug. The revelations coincide with an ongoing investigation by the Department of Public Health, which oversees patient safety, that found continued deficiencies at nearly 90 hospitals.

This is not very reassuring for anyone checking into a hospital.

Officials said that one out of four of the hospitals they inspected still had tainted heparin months after they were warned by pharmacy regulators to dispose of it. "We are looking at a complex situation and a breakdown," Kathleen Billingsley, a deputy director of the Department of Public Health, said. The botched recall raises questions about how hospitals, and their in-house pharmacies, respond to drug alerts. Some medical experts said the increasingly muddied distribution system for medications also played a role in the errors.

Muddied distribution system? Something else to worry about.