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Adverse Events Draw $775K in Fines at 9 CA Hospitals

Cheryl Clark, for HealthLeaders Media, October 28, 2013

6. At Mercy Medical Center, Merced, Merced County, a 2.5-month old infant's hands endured third degree burns, ultimately requiring skin grafts, because nursing staff failed to follow guidelines in starting an IV catheter.

The infant had been brought to the emergency department by her parents for treatment of 10-day diarrhea and vomiting.

When nursing staff were unsuccessful with multiple attempts to start an IV for fluids, the nurse supervisor used a "vaginal light, without its attached speculum cover, in order to illuminate the veins in the infant's hand," which was not the manufacturer's intended purpose.

The manufacturer's instructions say "Warning: Lamp is harmful to skin if touched… Lamp is hot and can cause burn if used outside of the vaginal specula."

Additionally, the nursing staff was faulted for multiple attempts to start an IV, when hospital policy limits each staff member to two attempts.

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

7. At Mission Hospital Regional Medical Center, Mission Viejo, Orange County, a patient admitted with an internal jugular catheter suffered cardiac arrest and respiratory failure and required intubation when a nurse not competent to remove the catheter did so improperly.

The nurse, who was from a contract agency and was not on the hospital's staff, removed the catheter while the patient was sitting upright in a chair instead of in a supine position, which is necessary to prevent an air embolism, according to a state report. The nurse reported that the patient "was in a hurry to go home, so she had pulled the internal jugular catheter out while (the patient) was sitting upright in a chair."

The penalty is $100,000. This is the hospital's seventh administrative penalty.

8. At Santa Clara Valley Medical Center, San Jose, Santa Clara County, two patients received 16.6 times more than the intended dose of the chemotherapy drug methotrexate when a pharmacy technician failed to dilute them with normal saline, as the physician ordered, and the pharmacist failed to catch it.

One of the patients was observed with "twitching" movements in hands and legs, became drowsy, and required transfer to the intensive care unit. Eventually the symptoms resolved and the patient was discharged home to hospice care.

The other patient developed seizures and "generalized body jerky movement with a cardiac arrest, and also had to be transferred to the intensive care unit for intubation.

The penalty is $100,000. This is the hospital's fourth administrative penalty.

9. At Sharp Memorial Hospital, San Diego, San Diego County surgeons removed a 53-year-old man's left kidney instead of his cancerous right one. As a result, he must undergo life-long dialysis.

"The surgical team failed to have any of the relevant images of the kidneys available and displayed during any part of the surgical procedure," the state report said.

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