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Medical Errors at 10 CA Hospitals Draw Fines of $625K

Cheryl Clark, for HealthLeaders Media, August 21, 2013

The inquiring nurse told investigators that the administering nurse "got a 'deer in the headlights look' when she told (the nurse) that the solution was not TPN but an enteral feeding formula [Glucerna]. She stated that (the nurse) 'immediately took the bottle of feeding formula [Glucerna] and the tubing off the pump and threw it in the trash. ' "

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

9. At Barlow Respiratory Hospital, Los Angeles, in Los Angeles County, a patient died after staff failed to notify physicians that he was having repeated episodes of abnormal cardiac electrical signals.

"When a patient experiences runs of VTACH [ventricular tachycardia], the patient should be assessed and the patient's physician should be notified."

A nurse "stated she entered the room and found the patient 'scratching on his chest' and 'became unresponsive.' According to (another nurse), she was not told of any arrhythmias or runs of VTAC? prior to the incident where she went into the patient's room." Despite medications, defibrillator shocks, and CPR, the patient was pronounced dead.

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

10. At Ronald Reagan UCLA Medical Center, Los Angeles, in Los Angeles County, a patient who underwent surgery to remove the gall bladder and pancreatic tumor resection had to undergo a second surgery to remove a forgotten lap sponge.

According to state investigators, the operating room record indicated that
sponge counts were correct.

"However, according to the discharge summary, on the fourth post-operative day, a Gastrogaffin study [swallowing of contrast followed by an x-ray] was done to assess for duodenal leak…, which did not show any leak. Instead, the study showed the ribbon-like structures in the left lower abdominal."

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

Higher Fines Pending
New regulations in the works will raise the maximum penalty to $125,000, says Debby Rogers of California's Department of Public Health's Center for Healthcare Quality. Since the penalties began in 2007, the state has issued 286 penalties to155 of the state's 450 acute care facilities.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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