Skip to main content

12 Hospitals Fined For Patient Harm, Deaths in CA

 |  By cclark@healthleadersmedia.com  
   June 06, 2011

Two patients died and two others came close to death because of medication overdose errors while a fifth patient succumbed from injuries due to a preventable fall, California officials said in the latest round of immediate jeopardy fines, this time totaling $650,000 imposed on 12 hospitals.

"I think this has created a heightened awareness in the community with the release of these penalties," Pam Dickfoss, acting deputy director of the Center for Health Care Quality, California Department of Public Health said in a news briefing Thursday. "Our goal in the department is to improve the quality of care for all hospitals."

California's monetary penalties against hospitals are among the strictest in the nation. In addition to fines for these incidents hospitals are fined $100 per day after five in which the event goes unreported to the state.

Since immediate jeopardy penalties law took effect in 2007, hospitals whose providers cause patient harm or death to patients, or who create situations that can do so, have received 185 immediate jeopardy fines totaling nearly $4.9 million. Those fines have been levied against 118 individual hospitals, about one in four in the state. Several hospitals have received multiple fines.

Asked if the fines are having their intended effect, Dickfoss said hospitals are still incorporating reporting of these events into their protocols and procedures, and "are educating their staff on adverse events." She expects that penalties will continue to be imposed and will even peak at some point before they begin to decline when more safety precautions are put in place.

Medical errors that place patients in immediate jeopardy of harm in 2009 or later are assessed at $50,000 for the first, $75,000 for the second and $100,000 for the third or more. State officials said hospitals are appealing 35 of the previously levied penalties.

The money is supposed to be used on projects that help hospitals collaborate to reduce certain targeted types of errors, although no projects have been launched to date.

Links to the reports can be found by county here.

The harmful events announced Thursday occurred at these hospitals:

1. At Palomar Medical Center in San Diego County, a 62-year-old woman died after a registered nurse "re-programmed her IV pump to deliver 100 ml/hour of morphine, instead of 3 ml/hour, which represented 33 times the amount" she should have received, according to state documents. The patient died 26 minutes after the IV infusion was stopped.

The incident occurred because "nursing (staff) failed to follow the policy for analgesics infusion on a medical oncology floor," which did not allow for analgesics to be administered through a 3 channel IV pump. 

She had been admitted the month before, after coming to the emergency room with shortness of breath and vaginal bleeding, and was diagnosed with uterine malignancy and metastatic disease to the lungs, and had undergone a hysterectomy, and was scheduled for palliative chemotherapy.

Palomar received a $75,000 fine, its second administrative penalty.

2. At Pomerado Hospital, also in San Diego County, another patient died when a patient with a documented history of confusion and agitation "got out of bed and fell to the floor, fracturing his skull in several places," and developing a bleeding within his brain, state documents said.

The patient was then minimally responsive following the fall, and was placed in an extended care facility on hospice, where he died four days later.

State documents said the patient had fall precautions in place and a tab alarm, but had removed them. A sitter to monitor the patient had been reassigned. Asked why a sitter was not used for the patient, "according to RN 2, the supervisor told her there were a hundred other things to do before utilizing a sitter."

Pomerado received a $75,000 fine, its second administrative penalty.

3. At Sharp Memorial Hospital, also in San Diego County, a heart attack patient died of an overdose of the medication Milrinone.

According to state documents, the staff member who administered the medication "had not demonstrated all the standards of competency for the Intensive Care Unit." The staff member had failed to properly program the Alans Medley Infusion Pump with the name and dose of the drug to activate its guardrail safety feature.

The staff member was "new to the hospital" and was undergoing clinical training with a preceptor in the medical intensive care unit.

According to the pump's tracker, "the entire dose of 100cc of Milrinone was administered within approximately 7 minutes" or 3.6 times the prescribed dose.

Sharp received a $25,000 fine for the 2008 incident.

4. At Contra Costa Medical Center in Contra Costa County, a 25-year-old woman who had just given birth received fentanyl and bupivicaine for pain intravenously instead of pitocin, (oxytocin-medication given immediately after delivery to control uterine bleeding), which prompted a Code Blue, state documents said.

"The medication error resulted in (the patient) experiencing seizures, cardiac arrest requiring cardiopulmonary resuscitation, intubation, transfer to the intensive care unit and an increased length of hospital stay."
 
The nurse who made the mistake said she looked for the pitocin (oxytocin) but could not find it, and looked back at the side of the bed where the epidural medication was, "thought it was the Oxytocin, and hunt it on the IV 'wide open' (meaning high infusion rate)," state documents said.

"In the rush of things I made a mistake. They (medications) don't look alike or feel alike. I just didn't check."

Contra Costa received a $50,000 fine.

5. At Promise Hospital of East Los Angeles, four doses of 600 mg (10 times more than prescribed amount per dose) of Cardizem CD were administered" to a patient, resulting in severe bradycardia, and an inability by the licensed nurse to obtain a blood pressure reading for nine minutes.

After a Code Blue was called, the patient required intubation, mechanical ventilation and administration of emergency medications.

According to state documents, a licensed vocational nurse said she transcribed the drug prescription incorrectly. "I meant to write 60 (mg). In the med DISPENSE, it (Cardizem 60 mg) is there already – the 60 mg, no need to override."

Promise received a $50,000 fine.

6. At Scripps Memorial Hospital in Encinitas, in San Diego County, surgeons left a 12-inch by 1 inch metal retractor in the abdomen of a 66-year-old woman admitted for a hemorrhoidectomy.

According to state documents, staff interviewed said "the surgeon did not say that he was using the retractor in the patient's abdominal cavity, so (the surgical technician) did not tell (the circulating nurse) to add the instrument to the whiteboard. (Surgical technician) added that sometimes a surgeon would say when he/she left instruments in the patient's body, but sometimes he/she did not."

"This failure resulted in (the patient) having to go back to the operating room for a second surgical procedure."

Scripps Encinitas received a $50,000 fine.

7. At Scripps Memorial Hospital in La Jolla, in San Diego County, members of the cardiac catheterization team forgot to remove a 28-inch guide wire in an 82-year-old patient's right common femoral artery.

The wire wasn't discovered for 29 days when the patient went back into a second hospital for a second catheterization after he complained of pain in the right groin and a lump at the site of the initial heart catheterization.

The hospital "failed to ensure adequate supervision of a cardiovascular technician while he deployed a femoral artery closure device at the end of a cardiac catheterization procedure," state documents said.

Scripps Memorial received a $75,000 fine, its second administrative penalty.

8. At AHMC Anaheim Regional Medical Center in Orange County, a surgeon mistakenly placed a shunt to remove constriction in a patient with a kidney stone, but did it on the left side instead of the right side. A history and physical performed in a physician's office, and subequently faxed to the hospital, "incorrectly identified the kidney stone as on the left side. However, a CAT scan faxed over" to the hospital "showed the kidney stone as on the right side."

The patient after surgery continued to have flank pain and now, additionally, bladder pain, before the physician discovered the stone was on the right rather than the left side, state documents said.

"The hospital failed to implement several procedures that help safeguard patients from wrong site surgery," the state said, including the failure to review the patient's consent form, verify the correct site and document that on the pre-operative checklist."

Anaheim Regional received a $50,000 fine.

9. At Peninsula Medical Center in Burlingame, San Mateo County, surgeons failed to remove a piece of sponge used during an eye procedure. In an outpatient clinic, a physician noticed a small fragment of sponge extruding from the conjunctiva of the patient's right eye. The patient had to undergo a second surgery that day to remove the fragment.

According to state documents, the hospital's operating room nursing director said, "They don't count sponges during eye surgery, the surgeon does an internal count in his head."

Peninsula received a $50,000 fine.

10. At Emanuel Medical Center in Turlock, Stanislaus County, hospital teams failed to follow its policies regarding safe use of droperidol, a drug used for nausea and vomiting, which has significant risk of potentially fatal adverse events if it is not used according to strict protocols. It also has been given a black box label by the U.S. Food and Drug Administration.

Patients who receive it must first undergo an electrocardiogram to avoid heart rhythm disturbances in some patients. And patients with certain heart function abnormalities should not receive it at all.

A review of the records for 12 of 61 patients who received the drug at this hospital during a three month period last year determined that five of them either had not had the required ECG testing or had test results that should have precluded them from receiving the drug.

The physician who prescribed the drug for those patients "said he wasn't aware of the hospital's requirements for prescribing the drug (and) wasn't aware of the boxed warning by the FDA..."

The state documents did not indicate whether any of the patients had suffered any adverse events as a result of their receiving the drug.

Emanuel received a $50,000 fine.

11. At Kaiser Foundation Hospital in San Francisco, a patient who underwent a Caesarean section had to undergo a second procedure to remove a 4-centimeter proximal segment of a fetal scalp electrode, state documents said. The patient developed abscesses.

State documents said that the electrode had become "entangled during the surgery" and that it was not a practice in the operating room to account for electrodes, although that policy will be changed.

Kaiser received a $50,000 fine.

12. At Dominican Hospital in Santa Cruz County, an oncologist transposed two numbers resulting in a testicular cancer patient receiving "100 mg. per meter squared per day of cisplatin instead of 20 mg. per meter squared, for the four days he was administered the chemotherapy." Additionally, the pharmacist, despite multiple checks, failed to implement policies and procedures to verify appropriate dose.

As a result, the patient developed ringing in the ears, a feeling of being bloated, difficulty urinating and other worsening symptoms requiring insertion of a catheter and had to be admitted to the intensive care unit with acute renal failure due to cisplatin overdose and a course of dialysis, according to state documents.

Dominican received a $50,000 fine.


Past immediate jeopardy fines:
November 2010
April 2010
January 2010
September 2009

See Also:

Commentary: CMS Needs to Come Clean on Immediate Jeopardy

Tagged Under:


Get the latest on healthcare leadership in your inbox.