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Medical Errors Draw Fines for 7 CA Hospitals

Cheryl Clark, for HealthLeaders Media, February 7, 2013

3. At Memorial Medical Center, Modesto, in Stanislaus County, a physician delayed for 17 minutes resuscitation of a patient admitted for an elective outpatient procedure to break down his bladder stones. During the 17 minute delay, the patient incurred irrevocable brain injury, and died 11 days later.

According to state documents, after the procedure, the patient was placed on a gurney to leave the operating room but began "thrashing."  A physician, MD 2,  administered the drug propofol, and the patient immediately calmed down, but in about 60 seconds, stopped breathing.

The physician inserted oral and nasal airways, but a pulse oximeter showed no oxygenation. The physician then administered oxygen by mask. But when a cardiopulmonary resuscitation monitor was brought in, it did not indicate the patient was breathing, and that he did not have a heart rate.

"At some point MD 2 stated another anesthesiologist came into the OR and suggested re-intubation. MD 2 stated he then re-intubated and mechanically ventilated Patient 1."  However no Code Blue was called. No one was assigned to document in the events when the patient was not breathing.

A registered nurse told state investigators: "MD 2's job was to be the captain of the ship and maintain the patient's airway and monitor the patient' vital signs and assess the patient...MD2 did not do his job. We reacted when we saw time was being lost and something needed to be done."

When asked the reason for the delay in resuscitation and calling a code blue, MD 2 told investigators, "I zoned out."

The penalty is $50,000. This is the Memorial's first penalty.

4. Also at Memorial Medical Center, Modesto, the wrong patient received an inferior vena cava filter to prevent a leg blood clot from traveling to his heart and lungs—a clot the patient didn't have.

According to state documents, the error occurred because an ultrasound for a second patient who did have a leg clot, and who was treated in the hospital the same day, was "intermixed" with the record for the first patient.

The mix-up was discovered only because some time later, the first patient returned to the ED, and a new ultrasound was performed showing no clot.

"The Director of Imaging Services (DIS) stated" that prior to the incident, "physicians did not routinely check to make sure the digital ultrasound read on one computer monitor matched the patient for which the electronic health record was being dictated on the other computer monitor," and that "the hospital had no policy and procedure on the processing and dictation of ultrasounds."

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

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