The California State Board of Pharmacy documented "major deficiencies" related to staff training and knowledge in 2019 at Sutter Coast Hospital's compounding pharmacy, which was recently placed on a three-year probation.
During a routine inspection in January 2019, an investigator noted "major deficiencies" related to compounding training among staff, according to documents on the probation agreement. The pharmacist in charge and her staff "had not conducted most of the training required prior to commencing compounding," the investigator found. When asked to demonstrate knowledge of "aseptic hand washing, garbing, cleaning of a controlled environment and the ability to accurately document each documented drug compound," inspectors found "major deficiencies" in employees' knowledge of these regulations.
The investigator also found the only sink available was in a restroom, despite pharmacy law requiring a sink with running water is within the "parenteral solution compounding area or adjacent to it." Staff failing to wear appropriate clothing and unsanitary conditions were also observed, according to the documents.
A probation began July 23 for the Crescent City, Calif.-based hospital's compounding facility, a disciplinary action related to the matters. During the probation, the hospital will be subjected to unannounced visits from the pharmacy board and will be required to provide quarterly updates to the state, provide five hours of compounding education for pharmacy technicians and pay an undisclosed fine.
The pharmacy has since worked with the state pharmacy board and violations have been corrected, a spokesperson for Sacramento-based Sutter Health previously told Becker's.
"We have partnered with the California Board of Pharmacy and have made significant investments at Sutter Coast's compounding facility," a spokesperson said. "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."