Aside from communication breakdowns, one of the most common patient safety errors at hospitals involves a simple failure to follow the organization's own policies and procedures. Whether it's adhering to certain medication administration protocols, verifying staff and temp staff competencies or sticking to assessment and monitoring protocols, too often, hosptial staff and physicians fail to fully comply, as a spate of recent, costly cases so clearly documents.
Thirteen hospitals this week were each fined an average of $50,000 by California's health department after inspections revealed life-threatening compliance issues. One hospital, John F. Kennedy Memorial Hospital in Indio, was slapped with at least four fines of $25,000 each due to deficiencies in medication administration, patient monitoring and competencies verification procedures.
Other hospitals assessed administrative penalties by the state included:
- St. Jude Medical Center in Fullerton, where a man being treated for a heart attack died after his heart monitor had been disconnected -- and went unnoticed by nurses. According to an internal investigation, the patient's heart monitor alarm also wasn't loud enough for staff to hear. The hospital was fined $50,000.
- California Hospital Medical Center in Los Angeles, where a woman who had been misdiagnosed as having an ectopic pregnancy--who wasn't even pregnant--was treated with chemotherapy drugs that suppressed her immune system, causing sores to appear on her mouth, throat and skin. That hospital was fined $50,000.
At John F. Kennedy Memorial Hospital, two nurses failed to follow protocol in the case of a five-month old infant who was brought to the emergency room in June 2008 with a fever of 105.4 degrees and a an abnormally high heart rate. The first nurse, a contract nurse hired through an agency, was found to have no clinical competencies, and failed to reassess the patient after initially recording temperature, heart rate and oxygen saturation level. (Official policy called for continuous reassessment.)
The second nurse, a newly hired graduate who also failed to have any clinical competencies and who had no advanced cardiac life support or pediatric advanced life support training, documented the infant's temperature on three separate occasions, but never recorded the patient's heart rate or oxygen saturation level. None of the other vital signs were recorded until a third nurse took over.
The hospital was fined $25,000 for the incident, and also was fined three more times for other failed compliances.
To read about all of the hospitals fined:
- Read the state's press release and its reports on inspections at each hospital.