Latest California hospital penalties include five patient deaths
Tuesday, February 4, 2014
The latest penalties issued to hospitals by the California Department of Public Health (CDPH) for a “violation or deficiency constituting an immediate jeopardy to the health and safety of a patient” include five events that led to the death of a patient, one that led to a patient suffering severe brain damage when she was hooked up to carbon dioxide, and one that led to a patient being put on a ventilator because of a medication overdose.
One hospital, Fountain Valley Regional Hospital and Medical Center in Orange County, was penalized for the fourth time since the state began issuing financial penalties in 2007. In this latest horrific blunder, a woman died from head injuries suffered when she fell off a table during a procedure and hit her head on the hospital floor. Huntington Beach Independent reporter Anthony Clark Carpio summarized the CDPH report of its investigation into the case:
The patient was admitted into Fountain Valley Regional to undergo an angioplasty, which is used to dilate the area of arterial blockage by using a catheter that enters through a large artery in the groin, according to the report.
It continued: A device called a Femostop was used to close the puncture area when the procedure was completed. Two certified radiologic technicians were responsible for implementing the procedure, which required them to turn the patient on her side and place a belt under her to secure the device.
As the technicians were placing the belt under the woman, the patient’s upper body slipped off the table and her head hit the floor, the report said. The technicians said in the report that the nylon sheet the woman was on was slippery.
Upon further investigation, the Department of Public Health determined that the two technicians were not approved to be using the device.
Other penalties that were issued for patient deaths:
At Bakersfield Memorial Hospital, a 63-year-old woman died because the battery was dead on the heart monitor she was attached to. The audible alarm that would have alerted staff to the dying battery had been turned off, and no one checked the visual monitor on the device. In the words of the CDPH report, “Facility staff failed to respond to a visual continual low battery alarm for up to 8 hours.” Normally the device would have been watched by a monitor technician, whose sole responsibility would be to watch the monitors. But during this incident, a registered nurse was filling in for the technician — and the nurse was also doing paperwork for newly-admitted patients, spent an hour as charge nurse and answered questions. “I don’t remember seeing the battery alarm,” the nurse told investigators. “I don’t know what happened.”
At Garden Grove Hospital and Medical Center in Orange County, a patient died after receiving an overdose of Versed, a powerful sedative, during a bronchoscopy. The nurse involved reportedly administered the overdose after not reading back the doctor’s order. Here’s how it’s described in the CDPH report (these reports never include the names of the medical professionals involved): “MD 1 said, ‘I asked RN 1 how much Versed had been administered.’ MD 1 elaborated, ‘I was shocked when he told me 4 milligrams. I didn’t order that.’ The physician looked down, shook his head, and stated, ‘If (RN 1) had read back the Versed order to me I would have stopped him.'”
At Mercy Medical Center in Merced, a patient died after receiving an overdose of the blood-thinner heparin during a heart catheterization. The CDPH report indicates lab technicians did not report crucial test results to the nursing staff, and the nursing staff did not report the patient’s symptoms of heparin overdose to the physician until two-and-a-half hours after they were first observed.
And at St. Joseph’s Hospital in Orange, a woman who had just delivered a baby by Caesarian section died “because staff failed to alert a physician that her blood pressure had dropped and her heart rate had increased for four hours,” according to Cheryl Clark of HealthLeaders Media. (The CDPH report is here.)
Another tragedy happened at Regional Medical Center of San Jose, where a 68-year-old woman suffered severe brain damage after she was hooked up to a tank of carbon dioxide rather than an oxygen tank. The error wasn’t noticed for at least 16 hours. (The CDPH report is here.)
A patient at Los Angeles Community Hospital received ten times the prescribed dose of the blood-thinner heparin after a pharmacist did not correctly transcribe the doctor’s order and the nursing staff failed to double-check the dosage, something they were required to do under hospital procedures because it is a “high-alert” medication. The patient coded, was intubated and put on a ventilator but did recover. (The CDPH report is here.)
The other penalty assessed in this latest round was against Ronald Reagan UCLA Medical Center, where a lab sponge was left inside a patient’s abdomen. A second surgery was necessary to remove the sponge. Medical staff are supposed to count surgical sponges and implements before and after procedures to ensure nothing is left inside patients, but the count was not done correctly in this case. (The CDPH report is here.)
Under California Health and Safety Code section 1280.1, hospitals can be fined up to $100,000 for these types of violations, but keep in mind that money goes to the state, not to those who were victims of the medical harm. And under California’s unjust and long-outdated MICRA law, victims of medical harm are limited in their compensation for so-called “noneconomic” damages, including the loss of a loved one and other types of pain and suffering, even though medical professionals are completely at fault. An initiative that is now being qualified for the November 2014 ballot, the Troy and Alana Pack Patient Safety Act, would update that cap on compensation to account for more than 38 years of inflation since the cap took effect in 1975.
A list of all penalties issued for patient safety violations since they began in 2007 can be found, by county, on the CDPH website.
— J.G. Preston
J.G. Preston is press secretary for Consumer Attorneys of California, which supports the Troy and Alana Pack Patient Safety Act.