It’s probably what we fear most when we have to go into the hospital. Getting the wrong medication or dosage, or having the wrong limb operated on or even amputated.
In California the stakes are getting higher, according to a story by Sandy Kleffman, in which the state fined 13 hospitals Friday, including facilities in Oakland and San Jose, for medical errors that endangered patients. Separate patients died at two of those facilities.
Kaiser Oakland and Santa Clara Valley Medical Center each received $75,000 penalties from the state Department of Public Health – particularly disturbing as it “was both facilities' second violation for a medical error,” Kleffman wrote.
At Kaiser Oakland, the patient, who died in 2010, was admitted to the hospital with pneumonia, congestive heart failure and an enlarged heart muscle, according to state documents.
At first, everything went the way it was supposed to. He was placed on a heart monitor that sets off alarms as abnormal and dangerous heart rhythms occur. A physician was to be contacted if the patient's heart rate went past 120 beats per minute. But although several alarms went off when the patient's heart rate soared from distress, nurses failed to respond or contact the physician.
Nurses also ignored several alarms indicating the monitor had a low battery.
The staff was able to resuscitate the patient, but he died after two more heart attacks.
“A nurse told state investigators he did not notify the doctor when the patient's heart rate rose because the patient frequently had a high heart rate, seemed to be all right and ‘always checked out fine,’” added Kleffman.
The doctor said he heard but did not react to an alarm, indicating a low battery because he “had a heavy assignment that night,” that other patients needed a lot of assistance, and that he lacked assistance.
The assistant nurse manager wasn’t much better. The pager worn by this staffer wasn’t even programmed to receive alarms revealing dangerous heart rhythms, so the manager could not respond as a backup.
"We deeply regret that this incident occurred," Barbara Crawford, Kaiser's vice president of quality and regulatory services, told Kleffman.?? Kaiser was also quoted to have taken immediate action “to revise [the center’s] cardiac monitoring procedures, train employees and monitor their compliance.”
Santa Clara Valley Medical Center's error occurred in 2010 after a patient arrived in the emergency department complaining of chest pain. He had a tracheotomy – a surgically created hole in the neck that goes into the windpipe – and was on a ventilator.
All would have been fine if a nurse – without a doctor’s order – removed the ventilator to transfer him to another unit. To add insult to injury, the patient was consequently moved by a technician unqualified to handle a ventilator patient, according to state documents.
A technician finally noticed that “the patient's eyes were rolled up, his lips were blue and he appeared to have no pulse.” The patient was resuscitated, but died five days later after his family discontinued life support.
"We deeply regret that the incident occurred, and we've taken it very seriously," hospital spokeswoman Joy Alexiou told Kleffman. "We have taken the measures to prevent similar incidents from occurring in the future."
Alexiou said the nurse involved no longer works at the hospital and was reported to the Board of Registered Nurses. The other 11 hospitals fined Friday received penalties from $50,000 to $100,000 for failing to protect a patient from sexual misconduct, properly insert a feeding tube and making a medication mistake.
Edited by
Braden Becker
