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Sanjay Marwaha, MD Physician-in-Chief Corwin N. Harper, MHA, FACHE Senior Vice President/Area Manager Central Valley Service Area Stockton Medical Office Manteca Medical Center Tracy Medical Offices Modesto Medical Center 7373 West Lane, Stockton, CA 95210 1777 W. Yosemite Avenue, Manteca, CA 95337 2185 W. Grant Line Road, Tracy, CA 95377 4601 Dale Road, Modesto, CA 95356 March 17, 2021 Elianna Florido REHS San Joaquin County Environmental Health Department 1868 E Hazelton Avenue Stockton, California 95205 Re: Kaiser Tracy Incorrect Waste Disposal Incident Dear Elianna, This letter is to inform your department of a mistaken disposal incident of a controlled substance (schedule II) non-hazardous drug medication from our Tracy Medical Office facility (2185 Grant Line Rd, Tracy, CA 95377). On March 4, 2021 a pharmacist in our out-patient pharmacy department was sorting 10 bottles of Oxycodone from the MESA safe cabinet to load into the KSLR robot. They scanned 9 bottles yet inadvertently discarded 10 bottles into the confidential waste bin, not realizing one bottle had not been emptied. On March 8, 2021 another pharmacist, while filling a prescription for Oxycodone tablets, realized the count on the perpetual log and the KLSR inventory did not match. They alerted management and an investigation began to identify where the drugs went. We confirmed with our Iron Mountain Representee Anthony Madrid that the plastic waste for destruction has been picked up and taken to the Covanta Stanislaus Waste to Energy Plan located at 4040 Fink Rd, Crows Landing, CA 95313 for incineration. Medication: 100 tablet bottle of Oxycodone 5 mg Corrective Actions: • After each refill of KLSL cassette, inventory will be validated for KL/perpetual inventory effective immediately. • All pharmacists are required to count the meds in the back C2 area and p lace the bottles on the cart prior to loading them in the machine effective March 15th. • All pharmacists are required to tap each empty bottle in front of the camera after loading into the KSLR machine prior to throwing the empty bottles March 15th. • All C2 control substances in the KSLR will be audited every night by the closing pharmacist. The pharmacy manager/PIC shall perform the weekly spot check effective March 15th. • All C2 control substances in the KSLR while being dispensed will be first logged by the technician/RPH and cosigned by another RPH effective March 15th. • Reeducate all pharmacists on Kaiser policy and procedures pertaining the control substance loss and inventory documentation effective by March 24th. • Provided notification to the Drug Enforcement Administration and The Board of Pharmacy.