UCSF vaccine error blinds man in one eye

A $100,000 penalty was issued Wednesday to the University of California at San Francisco Medical Center for failing to follow policies and procedures in administering a vaccine that left a patient blind in one eye, according to the state Department of Public Health.

The medical center at 505 Parnassus Ave. is now required to write out policies and procedures that would allow for safety in obtaining, storing, distributing, dispensing and using medicine, public health officials said.

Based on a survey completed in March 2012 conducted by state public health officials, a patient was given a chicken pox vaccine while suffering from conditions that placed the individual at risk for taking the agent, public health officials said. The patient was already immune to chicken pox before he was given the vaccine, according to public health officials.

The patient’s clinical record indicated a complex medical history that included common variable immune deficiency, a condition involving low levels of antibodies to overcome infections, according to the survey.

The patient was taking Prednisone, a steroid anti-inflammatory medication, to treat inflammatory bowel disease, and was undergoing intravenous immunoglobulin therapy, The vaccine manufacturer and Centers for Disease Control and Prevention had indicated that a patient receiving that medication and therapy should not receive the vaccine, according to public health officials.

The patient had developed “blurred visions and foreign object sensation” in 2011 that required hospitalization, public health officials said. The patient had to undergo multiple eye surgeries for chicken pox contracted to both eyes, and the patient is now blind on the right eye and suffers from inflammation of the retina to the left eye, according to the survey.

A documented consultation with an ophthalmologist stated that the patient might eventually suffer from glaucoma and need cataract surgery. The survey said clinical records did not provide a logical reason for why the patient was given the vaccine in the first place.

One doctor ordered the chicken pox vaccine, which contained a live virus, for the patient despite another doctor’s recommendation that the patient should only receive killed virus vaccines, public health officials said. The doctor that ordered the vaccine was not aware that the patient was already immune to chicken pox, according to the survey.

A nurse interviewed in the survey was not aware of any policies in place on patient screening before administering a vaccine, state public health officials said. The medical center has implemented an electronic health record system that replaced paper records in June 2011.

Health care providers and employees also received training in December 2011 to document conditions that would prevent a patient from taking a live vaccine. Any further attempts at ordering a live vaccine for a patient whose immunity would be compromised would prompt an alert to the ordering provider and nurse administering the vaccine, according to the survey.

The system would also give alerts for any live vaccines ordered for a patient whose immunity would be compromised. The new system was fully implemented in May 2013 in partnership with First Databank, a medical information vendor based in South San Francisco.