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Medical Errors Draw Fines for 7 CA Hospitals

Cheryl Clark, for HealthLeaders Media, February 7, 2013

The details of each incident, including each hospital's detailed plan of correction, are as follows, according to documents posted here by county:

1. At Adventist Medical Center in Hanford, in Kings County, a patient admitted for surgical repair of the right heel to decrease arthritic pain died shortly after the procedure because the Patient Controlled Analgesia (PCA) unit, through which he could self-administer morphine, lacked limits to prevent him from overdosing, state documents said.

"The Director of Pharmacy (DOP) stated Patient 1's morphine order was at the upper end of the dosing scale and that there was no documentation opioid tolerance was considered.

The DOP stated "...in my opinion, they (the Pharmacist) should have caught this; it was an unusually large dose...." The DOP  agreed that the facility did not have a policy and procedure for the safe use of PCA devices.

According to guidelines developed for safe use of PCA devices, PCA errors "represent a four-fold higher risk than other reported medication errors," and "Every clinician and hospital environment has a PCA (error) story."

The penalty is $50,000. This is Adventist's third penalty.

2. At Fresno Surgical Hospital in Fresno County, a patient admitted for an arthroscopic procedure on his left knee instead, requiring a second surgery.

"Patient 1 was brought into the OR 6 by RN 1 without rechecking to ensure the correct site (left knee) had been marked... As the team arrived, a time-out (a confirmation to ensure the OR team had the correct patient, side/site of surgery...) should have been announced, but this was not done at the time," state records say.

Later, after the prep on the wrong knee, a time-out was held with all team members present.

"The incorrect site was documented in the OR record as the correct site and no one visually verified the marking of the site to be operated on."

Days later, the patient told state investigators that he was having trouble walking to the bathroom because "he does not have a leg to bear weight on," and was having trouble using crutches as well.

The penalty is $75,000. This is Fresno Surgical's second penalty.

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