• Latest round of California hospital errors include patient deaths Friday, December 9, 2011

    Three patients died as the result of hospitals’ medication-related errors in cases included in the latest round of of penalties announced by the California Department of Public Health. Fines ranging from $50,000 to $100,000, depending on the hospital’s number of previous violations, were assessed to 14 hospitals for “noncompliance with licensing requirements [that] caused, or was likely to cause, serious injury or death to patients.” These errors are considered completely preventable.

    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

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