The patient also developed confusion, poor attention and concentration, "likely due to the lack of oxygen he sustained, and also due to the build-up of toxic elements due to kidney failure and shock liver."
According to physician progress notes, the patient "expressed the wish to just go to sleep. Faced with a lifetime of continued dialysis, and with increasing pain from gangrenous toes and fingers (the patient) and his family decided to stop all treatment. (The patient) died.
Investigators wrote that bottles of the two drugs "were seen to be approximately the same size," although Labetalol was a liquid and the Ceftriaxone was a powder," and one was blue and the other pink.
Penalty is $75,000. This is the hospital's third penalty.
9. At Children's Hospital of Los Angeles, in Los Angeles County, a physician erroneously ordered a dose of amphotericin B that was three times higher than the maximum dosage for a child admitted for a bone marrow transplant to treat acute myeloblastic leukemia and a fungal infection in the lung.
"The pharmacy staff failed to notice failed to recognize the dosing irregularity and the administering nurse failed to verify safe dose calculation."
The patient "subsequently experienced a cardiac arrest and expired."
According to the investigators' report, the bone marrow specialist on the patient's care team said the doctor had intended to order a different drug, Ambisome, but said physicians "often refer to Ambisome as amphotericin B" but which has a different form.
Penalty is $50,000. This is the hospital's first penalty.
10. At Fallbrook Hospital, Fallbrook, in San Diego County obstetric/newborn nursery staff failed to safely deliver medication related to the delivery of an infant following delivery.
As a result, the newborn received an injection of Methergine, a drug used to prevent and control postpartum hemorrhage in mothers following delivery, that was intended for the baby's mother.
The staff "further failed to intervene or advocate for the patients (in) reporting the medication error to the baby's or the mother's physician in a timely manner," which resulted in the baby developing seizures, being intubated, and requiring emergency transfer to another hospital, and multiple tests and treatments for seizures for some time.
According to the physician's report, the baby "will require further neurological examinations due to ischemic injuries (damage or death to brain tissue) seen on an MRI of the brain.)
The staff also failed to promptly notify a physician that a serious medication had occurred. "According to Physician X, he wasn't notified that anything had gone wrong until he came in the next day. Physician X stated that he would have expected to be notified right away" and if he had been, "he would have taken action immediately and called a pediatrician.
Penalty: $25,000. This is the hospital's first penalty.