When the patient wet the bed, a nurse inserted cloth padding on the spot, but the padding interfered with the grounding system used for the surgical cautery machine. "Heat in the presence or absence of acidic urine resulted in partial thickness chemical burns," according to Hi-Desert's Adverse Event Report, the state document says.
At Rady Children's Hospital in San Diego, San Diego County, a 3-year-old with cerebral palsy was given 89.5% phenol solution when the physician had ordered 5%, 2.5% in each leg in March 2009. When diluted, the toxic carbolic acid medication relieves muscle spasms and is supposed to be administered intramuscularly.
"Even though the 2 oz. bottle of phenol solution was clearly labeled with a much higher concentration, pharmacist S failed to identify that the prepared phenol solution was not what Physician M ordered," the state document says. Physician M "administered 2.5 ml of 89.5% phenol instead of 5% into each of Patient K's thighs" 17.9 times the concentration ordered, resulting in "inflammation and fluid build-up" in the patient's thigh muscles, which could have caused necrosis or cell death.
At Pomerado Hospital in Poway, San Diego County, last June, a patient with dementia in the facility's gero-psychiatric unit "was found by the licensed nursing staff in his room in a hospital style recliner chair that had fallen over backwards." A "personal alarm" system was not present, and there was no documentation in the medical record that the physician was notified of the incident.
According to the state document, inspection of chairs, one of which he used, "revealed that the cross bars . . . under the footrest were not intact."
Subsequent tests and autopsy showed the patient had developed bleeding in both the right and left sides of the brain "secondary to the fall" and "a result of blunt head trauma" and was transferred to an intensive care unit and later moved to a facility where the patient died.
This is the second fine against Pomerado since 2007. A hospital spokesman said that the staff extends sympathies to the patient's family, but may appeal the fine.
In Mission Hospital Regional Medical Center in Mission Viejo, Orange County, a newborn in April 2009 "became dusky, exhibited respiratory depression and required intubation" after receiving morphine sulfate injection intended for the mother. The baby was bonding "skin to skin" with the mother at the time.
State officials interviewed neonatal intensive care unit staff who said "it is thought the nurse might have injected the MS into the baby's running IV instead of the mother's."
Mission Hospital issued a statement saying it "is deeply concerned" about the incident and has "conducted a process review and provided ongoing education and training for our patient care teams with regard to administering medications."
At Alameda County Medical Center in Oakland, Alameda County, a patient died last October after staff "pushed" an IV dose of Dilantin in 5 minutes instead of over the course of an hour, as prescribed. Dilantin, used to prevent and manage seizures, has precautions for "hypotension and bradycardia, cardiac arrhythmias and cardiovascular collapse (especially with rapid IV use)," ultimately the cause of death for the patient.
The nurse "failed to recognize that the maximum rate of IV administration of Dilantin was 50 mg per minute," the state document said. This is Alameda's second administrative penalty.
At Marin General Hospital in Greenbrae, Marin County, a surgical team left a piece of laparoscopy tape sponge inside an obese patient during a Cesarean section last October. The tape was not discovered until three days later.
"The surgeon, the scrub technician, and the circulating nurse stated that there was confusion prior to closure, and the staff thought the last sponge was on the operative field," the state report said. Additionally, the patient's medical record did not include any mention of the retained foreign body or the exploratory laparotomy to remove it.
In a statement, Marin officials apologized for the incident and said they have implemented a monitoring system and are reeducating staff to make sure that nurses and physicians work collaboratively in tracking sponges.