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12 Hospitals Fined For Patient Harm, Deaths in CA

Cheryl Clark, for HealthLeaders Media, June 6, 2011

The money is supposed to be used on projects that help hospitals collaborate to reduce certain targeted types of errors, although no projects have been launched to date.

Links to the reports can be found by county here.

The harmful events announced Thursday occurred at these hospitals:

1. At Palomar Medical Center in San Diego County, a 62-year-old woman died after a registered nurse "re-programmed her IV pump to deliver 100 ml/hour of morphine, instead of 3 ml/hour, which represented 33 times the amount" she should have received, according to state documents. The patient died 26 minutes after the IV infusion was stopped.

The incident occurred because "nursing (staff) failed to follow the policy for analgesics infusion on a medical oncology floor," which did not allow for analgesics to be administered through a 3 channel IV pump. 

She had been admitted the month before, after coming to the emergency room with shortness of breath and vaginal bleeding, and was diagnosed with uterine malignancy and metastatic disease to the lungs, and had undergone a hysterectomy, and was scheduled for palliative chemotherapy.

Palomar received a $75,000 fine, its second administrative penalty.

2. At Pomerado Hospital, also in San Diego County, another patient died when a patient with a documented history of confusion and agitation "got out of bed and fell to the floor, fracturing his skull in several places," and developing a bleeding within his brain, state documents said.

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