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CA Fines 14 Hospitals for Medical Errors

Cheryl Clark, for HealthLeaders Media, August 31, 2012

2.  At Kaiser Foundation Hospital, Los Angeles, in Los Angeles County, multiple failures contributed to the death of a patient who pulled out her left femoral hemodialysis catheter and bled to death.

State documents say that a non-working cardiac monitor on the patient went unnoticed, a Vocera receiver alarm didn't go off  (possibly because staff weren't trained to use it), there was a low level of nurse staffing (two nurses were preoccupied with a narcotics count), and the wrist restraint the patient was ordered to have because of her previous attempts to tear out her catheter was loose.

"RN2 indicated that she had to be both the charge nurse and monitor technician and she thought the 'staffing [was] very unsafe,' " state documents say.

This is the hospital's first penalty and comes with a $50,000 fine.


3. At Kaiser Foundation Hospital, San Francisco, in San Francisco County, a patient received wrong doses of insulin and died because hospital staff did not remove the insulin pump that was attached to her body when she was admitted.  Meanwhile, physicians continued to give her doses of insulin to lower her blood sugar, and failed to notice when it dropped to 7 mg/dl, far below normal of 70-105).

Her cause of death was due to "anoxic encephalopathy due to hypoglycemia, (brain injury and death due to a low blood sugar)" according to the state report.

An RN told investigators that she didn't know whether the patient's insulin pump was on. "The patient's nephrologist (kidney doctor) came by and told the patient to turn it off. I think the patient turned it off, but she still had it on her body at the end of my shift."

This is the hospital's third penalty since 2009, which comes with the maximum $100,000 fine.

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