4. At St. Mary's Medical Center, San Francisco, in San Francisco County, a patient who had undergone a triple coronary artery bypass graft procedure died when a portable ECMO heart-lung bypass machine designated for intra-facility transport became disconnected as the patient was being transferred in an ambulance.
"The facility failed to follow the oxygenator manufacturer's recommendation to connect and band all blood lines," the state report said. "This failed practice resulted in the disconnection of the blood tubing from the oxygenator venous inlet and was the direct cause of the death of Patient 1."
State documents say that after the CABG procedure, "several attempts were made to wean (switch from heart-lung machine to person's own heart and lung) Patient 1 from the cardiopulmonary bypass machine" without success.
So an attempt was made to transfer the patient to another facility's intensive care unit to be placed on a long-term left ventricular assist device.
State investigators asked the hospital's risk manager if there were any facility policies or procedures for setting up the portable ECMO bypass system for intra-facility transport. "RM-1 said, 'No, we are working on writing them up now.' "
This is the hospitals first penalty, and carries a $50,000 fine.
5. At Stanford Hospital, Stanford, in Santa Clara County, a patient admitted for aortic dissection suffered lack of oxygen resulting in brain injury, and later death, after a nurse who was not qualified to do a procedure removed sutures that anchored the patient's tracheostomy tube.
"Removal of the sutures allowed the tube to become dislodged, causing a hypoxic episode resulting in brain injury," the state report said.
The nurse told investigators she cut the sutures in order to clean the area but did not obtain a physician's order first, and did not document what she had done in the medical record.
"By failing to timely report her conduct, Nurse A caused inexcusable delay in patient treatment. These actions caused or are likely to have caused, serious injury or death for the patient and therefore constituting an immediate jeopardy within the meaning of (the) Health and Safety Code," according to the state report.
The hospital was fined $50,000. This was its first penalty.