County Hospital Fined for Giving Wrong Medication

By Bay City News Service

The Contra Costa County Regional Medical Center in Martinez and three other Bay Area hospitals are among 12 in the state that have been assessed administrative penalties for violations of licensing requirements that are likely to cause serious injury or death to their patients.

The other Bay Area hospitals are Dominican Hospital in Santa Cruz, Mills-Peninsula Medical Center in Burlingame, and Kaiser Foundation Hospital in San Francisco.

Each hospital was assessed a $50,000 penalty. Penalty amounts range between $25,000 and $75,000.

The hospitals were required to provide a plan of correction to prevent future incidents and may appeal the penalties within 10 days.

Kaiser Foundation Hospital in San Francisco and Mills-Peninsula Medical Center in Burlingame were penalized for not following surgical policies and procedures.          

Contra Costa Regional Medical Center was penalized for not following policies and procedures for the safe distribution and administration of medication.          

Dominican Hospital in Santa Cruz was penalized for not following policies and procedures for on-going patient monitoring and assessment of patient care.         

During a teleconference on Thursday, Pam Dickfoss, acting deputy director of the Department of Public Health's Center for Health Care Quality, said there is a "heightened awareness" of patient safety in California and hospitals are taking the issue seriously.          

"Our goal is to improve quality care for all hospitals," Dickfoss said.

The Contra Costa Regional Medical Center was penalized for giving an epidural anesthetic medication instead of Oxytocin to a 25-year-old woman after she gave premature birth on May 17, 2010, according to the investigation by the Department of Public Health.          

The attending nurse said she "grabbed the epidural medication thinking it was the Oxytocin and didn't check the label," according to the investigation.         

"In the rush of things, I just made a mistake," the investigation quoted the nurse as saying.          

The woman had seizures, became unresponsive, was given CPR and was taken to the intensive care unit.          

The hospital agreed to take three corrective actions regarding its labor and delivery policy, medication administration and documentation. 

Kaiser Hospital in San Francisco was penalized for leaving a 4-centimeter segment of a fetal scalp electrode inside a Caesarian section patient's lower right pelvis on Nov. 29, 2008, according to the investigation.         

The woman suffered an infection and returned to the hospital three weeks later to have the electrode removed.          

The electrode became entangled during surgery and it was not the practice in the operating room to account for the number of electrodes, according to the report.       

Kaiser Hospital revised its policy and agreed to specifically count fetal scalp electrodes in the operating room, the Department of Public Health said.

Dominican Hospital in Santa Cruz was penalized regarding a patient who was to receive outpatient intravenous chemotherapy for testicular cancer on five consecutive days between Oct. 4-8, 2010.

The patient complained of ringing in his ears on the third and fourth day of treatment and also of feeling bloated, according to the investigation.

When symptoms worsened, the fifth day of treatment was cancelled.

The patient complained about difficulty urinating on Oct. 9 and was seen in the emergency room where a catheter was inserted to drain urine in his bladder before he was sent home.

When a physician's note indicated the patient had been given an excessive amount of the medication cisplatin, the on-call oncologist asked the patient to return to the emergency room.

The patient then received medication and fluids through a catheter in a large vein and was transferred to another hospital for a blood purification procedure, the report states.

It was determined the patient had suffered acute kidney failure from an overdose of the medication cisplatin. He received daily blood purification and dialysis and remained in the intensive care unit for 17 days, according to the investigation.

The patient's primary oncologist stated, "I discovered that I transposed 2 numbers in calculating his chemotherapy doses" causing the patient to receive five times the dose of cisplatin per day over four days, according to the investigation.

The hospital's pharmacist also failed to verify the appropriate dose and frequency of chemotherapy medication, the Department of Public Health said.

The hospital revised its policy on high-risk medication and a clinical pharmacist was deployed to review all chemotherapy orders.

The Mills-Peninsula Medical Center in Burlingame was penalized for leaving a small sponge fragment in the right eye of a glaucoma patient during surgery on Dec. 14, 2009.

When the patient complained of discomfort on Dec. 23, an exam found the sponge fragment extruding from the thin membrane that covers the white surface of the eyeball. The sponge was removed during surgery the same day.

The hospital's operating room director told the Department of Public Health sponges are not counted during surgery and the surgeon "does an 'internal' count in his head."          

"Counting sponges in eye surgery is an exception to the rule. We don't count eye sponges," a registered nurse's assistant said.

The hospital ordered special smaller sponges that have strings attached and strung nylon sutures on their existing sponges so it would be apparent if a fragment were left behind, the Department of Public Health said.         

The hospital also now requires sponges to be counted if they are used for any purpose. Measures also were taken to prevent pieces of sponges from shredding.