No Volt has caught fire as the result of a crash outside of a testing setting, but as we reported last month, two Volt batteries caught fire after the vehicles they were in were involved in crash tests. In one the fire started a week after the crash, in the other the delay was three weeks; in both cases the batteries had not been drained of energy after being stored, which is the recommended safety procedure for an electric vehicle involved in a crash.

After an investigation, the National Highway Traffic Safety Administration said it did not find a safety defect in the Volt and “issued new guidelines for how emergency personnel and tow truck operators should deal with electric vehicles and plug-in hybrids that have been damaged in severe accidents,” according to a report by Jerry Hirsch in the Los Angeles Times. Hirsch adds General Motors “is adding structural reinforcement that better protects the [Volt] battery pack from punctures or a coolant leak in a severe side crash.” A coolant leak resulting from crash damage caused electrical shorts that led to the fires in the test vehicles.

The Associated Press reports the NHTSA did not order a recall on the Volts, but GM is voluntarily retrofitting the 12,000 vehicles that have already been sold or put on the market. NHTSA officials say they don’t believe electric cars are at a greater risk of a fire than gasoline-powered vehicles.

The NHTSA has also been involved in investigating reports of sudden unintended acceleration in various Toyota models. In December a firm that has been critical of NHTSA’s investigation, Safety Research & Strategies, filed suit to gain access to agency records, and this week it did so again, with an accusation that NHTSA was covering up a demonstrated acceleration defect. From the SR&S blog:

In mid-May, two engineers from the National Highway Traffic Safety Administration’s Office of Defects Investigation witnessed a 2003 Prius, owned by a high-ranking government official, accelerate on its own several times while on a test drive with the owner, without interference from the floor mat, without a stuck accelerator pedal or the driver’s foot on any pedal.

“They said: Did you see that?” the Prius owner recalled in a sworn statement.  “This vehicle is not safe, and this could be a real safety problem.”

They videotaped these incidents, excited that, at long last, they had caught a Toyota in the act of unintended acceleration, with a clear electronic cause. The engineers downloaded data from the vehicle during at least one incident when the engine raced uncommanded in the owner’s garage and admonished the owner to preserve his vehicle, untouched, for further research.

But three months later, the agency decided that there was no problem at all. The agency thanked the Prius owner for his time and said that it was not interested in studying his vehicle. This critical discovery was never made public. The agency did not even put this consumer complaint into its complaint database, until months later, at the request of Safety Research & Strategies.

The Prius owner in this story is Joseph H. McClelland, an electrical engineer and the director of the Office of Electric Reliability for the Federal Energy Regulatory Commission.

U.S. Transportation Secretary Ray LaHood said last year, “There is no electronic-based cause for unintended high-speed acceleration in Toyotas.” But SR&S president Sean Kane said McClelland’s Prius tells a different story:

For years now, Toyota has been telling the public that there are no causes of unintended acceleration in their vehicles beyond floor mats, sticky pedals and confused drivers. NHTSA has stood by their side nodding in agreement. The two have repeatedly told consumers that the incidents they have reported – as they have reported them – could not have happened. Mr. McClelland’s Prius and the NHTSA investigation of his unintended acceleration put the lie to all of that. Unintended Acceleration in Toyota vehicles continues to this day, and the public has a right to know why.

SR&S has filed a Freedom of Information Act suit to gain access to the materials related to the McClelland vehicle test. New York Times reporter Bill Vlasic wrote McClelland did not respond to the Times’ requests for an interview but had said in his sworn statement he was told by NHTSA investigators his vehicle’s age (2003 model) and high mileage (280,000 miles) were the probable causes of his problems.

An NHTSA response to the Times said the agency would not reopen its investigation into Toyota unintended acceleration issues: “the exhaustive 10-month study made clear there are two mechanical causes of sudden, high-speed unintended acceleration in certain Toyota vehicles: pedal entrapment and sticky pedals.” The statement went on today, “NHTSA concluded that the speed of the [McClelland] vehicle could easily be controlled by the brakes. In contrast to other UA [unintended acceleration] complaints, the vehicle displayed ample warning lights for the driver indicating the car had encountered problems.”

Kane’s response:

Is NHTSA saying that it is acceptable for a vehicle to have an uncommanded acceleration as long as there are some flashing lights and the vehicle is controlled by the brake (or in this case, was able to shift into Neutral)? What about all the drivers too surprised by the complete unpredictability of their Toyota to effectively apply the brake or shift in time? Or the drivers who don’t have enough time and distance to bring the vehicle to a safe stop? What about the instances in which the throttle opening is larger, and control of the brakes much harder than it was in the McClelland vehicle?  If this sort of vehicle behavior is acceptable, what, exactly, is considered unacceptable by this taxpayer-funded, federal, safety agency?

Meanwhile, in a report on The Huffington Post, reporter Sharon Silke Carty wrote that a NASA report last year that was seen by Toyota and NHTSA official as exonerating the vehicles’ electrical systems actually included “details that safety experts construe as disturbing evidence of problems potentially afflicting the electronic systems governing the gas pedal — problems that Toyota and the highway safety agency have so far dismissed”:

Investigators found so-called tin whiskers — which grow on tin when it is electrified and can conduct electricity to unintended places — inside the electronic systems in Toyota Camry gas pedals, according to the report. These wiry fibers of metal are thinner than a human hair and can sprout unpredictably. They have been implicated in crippling defects besetting a range of equipment, including communications satellites, pacemakers, missiles and nuclear power plants.

Carty acknowledged tin whiskers had not been identified as the cause of any Toyota fatal crashes, but “the mere confirmed presence of tin whiskers demands deeper investigation before such a causal link can be ruled out.”

–J.G. Preston

No related posts.

No related posts.

No related posts.

No related posts.

No related posts.

St. Jude Medical Center in Fullerton was fined $75,000 after a patient there died of a morphine overdose — ten times what the physician had intended — administered by a recently-hired nurse. The patient had gone to the emergency room after an accidental overdose of medication to treat high blood pressure. The nurse misunderstood a statement by the doctor, who apparently for some reason was describing the morphine dose that could be used in palliative care, and changed the dosage administered by the patient’s morphine pump to that higher amount. The nurse also failed to get a second nurse to verify the dosage change as required.

Within an hour, the patient was dead of acute morphine intoxication. The nurse who administered the overdose resigned.

Two deaths involved elderly patients who died of pneumonia even though they had been vaccinated against it at the Kaiser Foundation Hospital in South San Francisco. The vaccines they received had been compromised by being improperly stored at below-freezing temperatures. Several other patients were hospitalized with pneumonia after receiving the ineffective vaccine.

The pneumonia vaccine was one of several medications stored together at improperly-cold temperatures over a 32-month period; those drugs were administered to nearly 5,000 patients. Katharine Mieszkowski reported in The Bay Citizen that an engineer who was supposed to schedule preventive maintenance checks on the refrigerator in question every three months had instead scheduled them for every three years, and the hospital’s pharmacy director admitted to state investigators that no one was responsible for monitoring the refrigerator’s temperature, allowing the problem to continue for such a long time.

The Department of Public Health also criticized the hospital for not notifying all the patients who had received the compromised medications about the error. Instead the hospital notified only those patients it thought were at high risk. One of the patients who died was not told of the need to be re-vaccinated.

Another medication error resulted in a patient needing kidney dialysis. The patient at the Henry Mayo Newhall Memorial Hospital in Valencia was administered six overdoses — each three times the amount the doctor intended — of an intravenous antibiotic and suffered acute kidney failure. State investigators determined the doctor’s instructions were unclear.

And yet another medication error affected a newborn at Lucile Packard Children’s Hospital at Stanford. After the newborn had surgery to repair a congenital heart defect, intravenous medication was not properly diluted by the hospital pharmacy technician and pharmacist. The newborn wound up getting more than 13 times the amount of ammonium chloride per dose, resulting in seizures. The child required intubation for several days as a result of the error.

Half of the fines involved items that were left in patients after surgery:

Fresno Surgical Hospital: A woman who had a hysterectomy continued to suffer from pain and infections after she was sent home; after eight months on various antibiotics she collapsed at home, was hospitalized and placed on intravenous antibiotics for 11 days. Two days after she was sent home, she started to feel terrible again and underwent surgery at a different hospital that found a surgical sponge that had been left in her after the hysterectomy. “I feel like I have been robbed of my life having to live with this,” she told investigators, and says she still suffers from a weak bladder and incontinence as a result.

LAC+USC Medical Center, Los Angeles: A patient who had an appendectomy wound up back in the emergency room and was diagnosed with small bowel obstruction resulting from adhesions from surgery. Checking a radiograph after surgery to break the adhesions found a sponge that had been left inside during the appendectomy, requiring yet another surgery to remove it.

Mission Hospital Regional Medical Center, Mission Viejo: A 71-year-old woman had back surgery to place a mental implant, but a metal breakaway tab from the cross-link was left inside her. The tab was found on a X-ray and she had a second surgery that night to remove it.

Scripps Memorial Hospital, La Jolla: During spine surgery, a one-inch pin used to stabilize the spine was left inside the patient. Afterward the patient complained of discomfort; she first said something was stuck in her throat, then said she felt something moving in her neck, then reported difficulty breathing, An X-ray found the pin, and a second surgery was required to remove it. The pin had been seen in an earlier X-ray but it wasn’t believed to be a foreign object. (This was the sixth penalty Scripps has received since the DPH started issuing them in 2007. Only Southwest Healthcare System in Riverside County has received more, seven.)

Sutter Solano Medical Center, Vallejo: A new mother discharged from the hospital after a caesarian section returned to the ER with severe abdominal pain. Surgery found a sponge that had been left in her after the C-section.

Torrance Memorial Medical Center: A patient underwent surgery for esophageal cancer, then a later X-ray found a sponge had been left in the patient’s abdomen, requiring a second procedure to remove the sponge.

Ventura County Medical Center, Ventura: Two weeks after abdominal surgery to close a colostomy, the patient went to the emergency room with abdominal pain and swelling, nausea and vomiting. A second surgery found a thin surgical towel had been left in the abdomen during the first surgery.

Two penalties were surgery-related. A woman received a partial mastectomy instead of a full mastectomy at San Francisco General Hospital. The patient changed her mind after first signing a consent form for a partial and later signed a second consent form for the full. While preparing the patient for surgery, a nurse failed to confirm the procedure that was to be done. Later the patient expressed concern to a second nurse about having signed two consent forms and said she wanted a full mastectomy; that nurse saw two conflicting consent forms but did not follow up, instead telling the patient to talk to surgeon, but the surgeon did not see the atient until after she was under anesthesia.

In the other case, at UCSF Medical Center in San Francisco, a surgeon made an incision near the wrong eye of a patient who was having surgery to relieve blocked tear ducts. After making the incision, the surgeon realized the mistake and performed the proper procedure. This is the sixth penalty UCSF has received from the DPH.

The other penalty handed down was not related to medical negligence but rather for lax security leading to the abduction of an infant from Santa Barbara Cottage Hospital by a woman posing as a nurse. The woman was arrested at her home a few hours later and is now serving a sentence in state prison. The child was returned to its parents unharmed.

–J.G. Preston

No related posts.

No related posts.