The error apparently was provoked because of a shortage of the preferred medication, arginine hydrochloride. A manufacturer's e-mail indicated ammonium chloride could be substituted if diluted. "The pharmacy technician prepared the patient's medication without following the hospital procedure to dilute the medication according to the drug's dilution card," according to the state report.
Lucile Packard was fined $50,000 for its second penalty since 2007.
6. At Mission Hospital Regional Medical Center, Mission Viejo, in Orange County, a surgeon neglected to remove a breakaway tab, which went undetected because, according to state documents, the hospital's count practices did not include these tabs, in violation of its own policy. The patient had to undergo a second general anesthesia for surgery to remove the retained tab.
Mission was fined $100,000. This is the hospital's fourth penalty.
7. At San Francisco General Hospital, in San Francisco County, a patient diagnosed with breast cancer originally signed a consent for a partial mastectomy, but later changed her mind and signed a second consent for a full mastectomy, the state report indicates.
The patient awoke to find that she had undergone a partial mastectomy instead a full one.
The patient recalled that the surgeon "apologized by saying 'At least we didn't do a mastectomy instead of a lumpectomy.' She said, 'I felt so neglected, I was left on a gurney in a hallway for four hours, and I never saw her (Surgeon 1), she never spoke to me..."
The patient told state investigators, "I'm not going back there, I don't trust them," according to the state report.
8. At Santa Barbara Cottage Hospital, in Santa Barbara County, hospital staff failed to prevent a newborn from being abducted from the mother's room, despite both were wearing security bands that sound an alarm if the baby leaves the mother infant unit (MIU).
"A woman wearing scrubs entered the mother's room and told the mother that she was taking Baby A to do footprints," according to state documents. "Baby A's mother agreed to allow the woman to take the baby from the room." A nurse who later entered the room found the baby's bassinet empty and the infant's security band, which was intact, in the bassinet.
"Despite the tamper-proof feature, it was possible for the abductor to remove the band from the baby's ankle intact, and the alarm was not set off."
State officials said the hospital had no security guard on the unit, and the facility "had no access control policy in place, i.e. a defined methodology of who can come, go, and how to limit access to the security-sensitive MIU." Also, state documents indicate that "nurses were utilized as the access control mechanism, but were not adequately trained and when busy could not account for visitors or the security of the unit."