Kaiser Permanente's South Bay Medical Center has been fined $50,000 for giving the wrong medication to a woman who died in surgery two years ago, state officials disclosed Thursday.
The state Department of Public Health reported that the Harbor City hospital has taken a series of corrective measures to prevent such lapses in the future.
The hospital reported its mistake on July 21, 2010, shortly after the patient died, officials said. The date of her death was redacted from public documents to protect her privacy.
The woman was admitted to Kaiser Permanente because she was vomiting blood, according to the health department's investigative report. Doctors believed she had stomach bleeding and took her in for surgery to repair a bleeding vessel.
During the operation, a doctor called out for a blood-clotting medicine called Activated Factor VII. After a series of mistakes, the patient was instead given a blood-thinning medicine called alteplase or Activase, according to the report. A nurse reported hearing the doctor ask for Activase rather than Factor VII, and then the administering doctor did not check the medication label before injecting it, the report said.
As a result, the patient had profuse bleeding from the hole in her abdomen, resulting in organ failure, shock from blood loss and death.
Kaiser spokesman Michael Pucci said hospital staff immediately reported the mistake and instituted corrective measures.
"We sincerely regret that this error occurred in 2010 at the Kaiser Permanente South Bay Medical Center," Pucci said in a written statement. "We have very stringent processes and policies in place and, while instances of administering the wrong medication are rare, we take any incident like this extremely seriously. We embrace that accountability and these rare errors reinforce our commitment to continuous improvement, patient safety, and high-quality care."
The health department's report indicates that the anesthesiologist administered the wrong medication because he did not read its label before using it.
To prevent something like this from happening again, the hospital has introduced more stringent processes for verbal orders in the operating room. Now, doctors and nurses receiving a verbal medication order during surgery must repeat it back, along with the dosage and route of administration. Then the doctor must confirm the order. Pharmacists must also double-check with doctors any time Activase is ordered.
California Department of Public Health's spokesman Ralph Montano said this is Kaiser South Bay's first such penalty. Eleven other hospitals were fined Thursday for similar errors, including one for Kaiser's Oakland/Richmond hospital because a woman died after going in to have a birthmark removed from her face. The surgeon improperly used a laser-beam cutting device, allowing gas bubbles to get into her blood stream and causing her heart to stop. That hospital received a $100,000 fine because it was its third such violation.
State officials undergo thorough processes to investigate errors like these and prevent them from happening again, Montano said.
"We do a surprise inspection of the facility, and the investigation takes three to five days," Montano said. "They respond with a plan of correction, which we either accept or decline. Once we accept their plan, we do another surprise inspection to make sure they're doing everything in the plan. If they don't, we issue them another deficiency."
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