The staff failed to use sterile alcohol even though a Lompoc hospital policy required sterile alcohol for cleaning areas in the hospital pharmacy. Instead of following proper procedures the hospital staff negligently used non-sterile alcohol and non-sterile water to clean the pharmacy area where IV medications are mixed. This finding was reported in the CMS Report of February 10, 2017, Page 37.
Lompoc hospital CEO Jim Raggio commented on this matter in the Lompoc Record.
“Nobody even knew that there was even sterile alcohol….”
The CEO’s statement is inconsistent with the hospital’s Policy and Procedures for Sterile Compounding (dated 10/16). The policy states: “Clean with sterile water and wipe down with dry cloth… the surfaces of the direct compounding environment will be sanitized with sterile 70% isopropyl alcohol (IPA) using a non-linting wipe.” (CMS Survey, page 58)
We asked Lompoc two hospital nurses if hospital staff and administrators didn’t know about the use of sterile alcohol. They rolled their eyes.
Here is a handout that describes the requirement for sterile alcohol and sterile water for cleaning the area in the pharmacy where drugs are mixed. This standard has been in place since June 1, 2008 (USP 797).
Why Is “Sterile Alcohol” Required?
It’s simple. Potentially fatal airborne pathogens can survive in non-sterile alcohol and non-sterile water.
Potentially Fatal Airborne Pathogens Survived In Hospital Pharmacy
The Lompoc hospital’s own records showed that staff knew that potentially fatal airborne pathogens (Staphylococcus coagulase) were present in the pharmacy during air tests in 2016. Yet, the hospital staff failed to eradicate the dangerous pathogens. Failing to maintain drug sterility can lead to tragic results.
Contaminated Medications Can Kill
In March 2017 the head pharmacist of the New England Compounding Center was convicted in a criminal trial. Hundreds of patients injected with steroid products from that pharmacy had suffered and sixty people had died from fungal meningitis. The pharmacy had failed to comply with the required standards that ensure drug sterility.
One can imagine what might have happened if CMS had not discovered the problems in the Lompoc hospital pharmacy. (The Director of the Pharmacy was replaced by hospital management.)