State fines 3 Southern California hospitals for patient safety violations

The California Department of Public Health has penalized three hospitals in Southern California with fines totaling $167,775, after investigators determined the hospitals had committed safety violations that led to the injury or death of patients.

Among the hospitals fined were Saddleback Memorial Medical Center in Laguna Hills, UCI Medical Center in Orange and Eisenhower Medical Center in Rancho Mirage.

According to state investigators’ reports, the incident at Saddleback Memorial occurred early morning Jan. 23, 2017. The report said a safety attendant left three suicidal patients unattended. One of those patients, who suffered from bipolar disorder, ran out of the hospital and onto a nearby freeway where he was struck and killed by a car, investigators said.

The state fined Saddleback Memorial $71,250 in connection with the incident.

Saddleback Memorial issued a statement Friday, Feb. 8, that it is “committed to providing the highest quality of medical care and ensuring patient safety.”

“We regret this incident, and acted upon it immediately,” the statement said. “We reported it swiftly, conducted a thorough review of the events and circumstances, and in furthering our commitment to patient safety, took decisive action to strengthen our rigorous policies and procedures.”

The incident at UCI Medical Center occurred Nov. 14, 2017 when a patient with brain cancer was given 200 times the prescribed dose of etoposide, a chemotherapy drug, according to investigators. The excessive dosage was attributed to errors on the part of a pharmacist and technician. As a result, the patient was hospitalized in the intensive care unit and “had a rapid, progressive decline in neurological status,” the report said.

She lost consciousness over the next two weeks and died several months later. UCI Medical Center was fined $47,025 for this safety violation.

UCI Health spokesman John Murray said the hospital takes “this matter very seriously as patient safety is our highest priority.”

“UCI Health conducted a thorough review of our processes and procedures to determine how and where the system failed,” he said. “We identified ways to improve the management and handling of high-risk medications across our organization, including changes in pharmacy, nursing and physician practices.”

The incident at Eisenhower Medical Center in Rancho Mirage occurred July 20, 2017. Officials said the patient came to the hospital’s emergency department for an irregular heart rhythm, but a resident used a defibrillator improperly.

This caused the patient to sustain cardiac arrest and “infiltration of medications into the patient’s arm resulting in compartment syndrome,” a painful condition that occurs when pressure within the muscles builds to dangerous levels. She also required a prolonged hospital stay and multiple surgical procedures, suffering loss of function in her right arm.

The hospital was fined $49,500 for this safety violation.

The incident involved a patient who “received a routinely provided urgent cardiac procedure,” said Christine Johnstone, vice president, quality and process improvement at Eisenhower Health.

“During one of these visits, an unanticipated event occurred involving cardiac equipment resulting in an unexpected heart rhythm,” she said. “The patient was treated following this event according to cardiac standards of care.”

The patient recovered from the incident and continues to receive care from Eisenhower Health, Johnstone said. She added that the hospital is providing “supplementary education and training to physicians and staff to reinforce appropriate procedural steps as well as reporting events that occur during patient care.”