California Hospitals Fined for Alleged Immediate Jeopardy Mistakes

Cheryl Clark, for HealthLeaders Media , January 28, 2010

"The patient's bedside monitor showed no heart rhythm. Resuscitation was attempted for 21 minutes, was unsuccessful and the patient was pronounced dead," the state concluded.

6. At Los Angeles Community Hospital, staff failed to apply soft restraints to a patient, as a physician ordered, leading to the patient removing his tracheostomy, the investigators wrote.

"Additionally, Patient 1 was subjected to a delay in airway management when Staff B failed to establish an open airway and administer oxygen immediately after finding the patient had pulled out his tracheostomy tube. A Code Blue was called, and during the cardiopulmonary resuscitation, the patient was found with no vital signs. Patient 1 subsequently expired due to cardiorespiratory arrest."

7. At Kaiser Foundation Hospital in Oakland, emergency room staff failed to double-check medication orders with drugs sent from the pharmacy. The error resulted in a 90-year old patient receiving a variety of blood pressure and stomach ulcer medications and potassium chloride intended for a different patient.

A rapid response team was called in when the man went into "severe respiratory distress, breathing 4-6 breaths per minute" and with a fluctuating blood pressure." A physician interviewed by the investigators "said he could not rule out that the blood pressure medications administered in error caused the severe change in Patient A."

The man was intubated and on a ventilator, and his "brain was not responding ... the ventilator … is keeping him alive," the investigators wrote.

8. At Marina del Rey Hospital in Los Angeles officials failed to assure that a registered nurse continuously assessed a patient's oxygenation when the cardiac monitor strip documented decreased oxygen. The failure resulted in a decrease oxygen saturation and a Code Blue, and the patient had to be intubated and connected to a ventilator, said the state.

9. At California Hospital Medical Center in Los Angeles, staff erred in administering Methotrexate, a chemotherapy, to a patient as treatment for ectopic pregnancy. In fact, the patient was not pregnant. And over the next eight days, the patient developed immunosuppression, severe neutropenia, leukopenia, renal function decline, and oral, esophageal and skin ulcerations, according to the state.

The "policy and procedure failure, relating to the use of chemotherapeutic medication on a patient who was not pregnant, resulted in Patient 1 being erroneously administered Methotrexate and subjected the patient to serious complications and harm," the investigators wrote.

10. At Western Medical Center in Santa Ana, surgeons left a laparotomy sponge in a patient during an emergency Cesarean section and "failed to conduct appropriate sponge, needle and/or instrument counts," investigators wrote.

"Patient #1 had to undergo the risks of another major surgery and general anesthesia to remove the retained sponge," investigators wrote.

11. At Sharp Memorial Hospital in San Diego, the surgical team forgot a sponge in the pleural cavity during an aortic valve replacement procedure. The sponge "had to be removed during a second surgical procedure," the investigators wrote.

12. At University of California San Diego Medical Center, state officials said, a patient required additional invasive procedure to remove a retained guide wire from his right atrium. The state report said the procedure was performed by a first-year intern with a third-year internal medicine resident in attendance for supervision. This is UCSD's third fine.

13. At San Francisco General Hospital, surgeons left a 4-inch by 8-inch gauze sponge in a patient. The object went unrecognized for three months when the patient returned to the hospital complaining of a foul-smelling discharge. "The sponge was not detected until it had tunneled through her abdominal wall into her vagina," according to the state.

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