State documents report that a physician involved (MD 1) said "he noticed the patient's condition changed (respiratory rate and level of consciousness) after administration of Versed.
MD 1 said, 'I asked RN 1 how much Versed had been administered.' MD 1 elaborated, 'I was shocked when he told me 4 milligrams. I didn't order that.' The physician looked down, shook his head, and stated, 'If (RN 1) had read back the Versed order to me I would have stopped him?I said Versed 1 milligram or .5 milligrams."
This is the hospital's third administrative penalty.
4. Los Angeles Community Hospital, Los Angeles
County: Los Angeles
A patient received a dose of heparin 10 times higher than what was ordered because, according to state documents, "the pharmacist failed to transcribe the order correctly" for a heparin drip, a high-alert medication.
"Subsequently, the patient experienced bleeding from orifices around the surgical site, decreased blood pressure, and respiratory distress that eventually required resuscitation and mechanical ventilation support."
This is the hospital's second administrative penalty.
5. Mercy Medical Center, Merced
County: Merced County
Failure to do proper blood clotting tests and respond to them before and during a heparin drip resulted in an overdose that caused a patient death.
Though lab tests were done, they indicated clotting at greater than 400 seconds. "The lab considered the results erroneous and did not report them to the RN. Rather, the lab redrew the [blood]?Again the results were greater than 400 seconds?"