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Southwest Healthcare: How Could So Much Be So Wrong?

Cheryl Clark, for HealthLeaders Media, April 21, 2010

According to the April 15 letter from Chickering, "The findings indicate that many previously identified systemic problems persist. The survey also documented the inability of the hospital's governing body to identify and take appropriate measures to eliminate clear threats to patient health and safety." Some of the problem areas include:

  • Nursing services, the hospital failed to ensure nursing staff administered blood pressure medications as ordered by the physician and failed to administer the first dose of antibiotics to patients to prevent infection within the first two-hour timeframe. It failed to ensure a patient with a low-blood pressure was rechecked to prevent its continued decline.
  • Medical staff, the hospital failed to assure that six physician's assistants were competent to do medical screening exams in the emergency department.
  • Infection control, the hospital's providers did not always wear face masks and surgical head coverings in the cardiac unit where pacemaker insertions and catheterizations took place.
  • Pharmacy, a pharmacist did not ensure that medications with black box warnings were used safely and failed to ensure that the medication preparation area for chemotherapy agents was properly decontaminated, "thereby potentially exposing other patients to chemotherapeutic agents, and their side effects."
  • Physical environment, the hospital failed to ensure newborns were safe from abduction because an alarm system that was removed was not replaced and security guards could not visualize hallways leading to the nursery.

On Monday, state health officials took the rare step of creating a separate Web page documenting a timeline of Southwest Healthcare's problems from June 2007, when federal surveyors determined the hospital had insufficient physicians on call. And, the list goes on.

That incident resulted in a federal letter citing non-compliance in three conditions of participation saying that patients with life-threatening injuries w delayed "by up to eight hours."

In October 2007 surveyors discovered 13 conditions of participation that had gone unmet, "placing more patients in immediate jeopardy in two ways:

  1. Inadequate emergency supplies of medication available to treat life-threatening medical emergencies.
  2. "The hospital failed to ensure proper food control, placing patients and visitors at risk for serious harm due to potential growth of microorganisms and food borne illness."

I asked Billingsley if the hospital might have had funding problems. She said she didn't think that is the issue. Well then, what is?

It's hard to understand how two hospitals—and one health system—couldn't fix problems that had been going on for so long. It truly begs the question:

How can so much be so wrong with Southwest Healthcare? And why was it allowed to go on for so long?


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Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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