12 Hospitals Fined For Patient Harm, Deaths in CA

Cheryl Clark, for HealthLeaders Media , June 6, 2011

"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.

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