State and federal health officials investigated UC Irvine Medical Center in California after a kidney transplant patient, who received too much medication from a drug pump, died in July, reports the Los Angeles Times.
The California Department of Public Health and the Centers for Medicare & Medicaid Services (CMS) found inadequately trained staff were dispensing medication through the new infusion pumps, jeopardizing patient safety. They also discovered the hospital failed to create any policies that set specific standards to safely use the pumps.
The hospital didn't program the drug pump to prevent an overdose, enabling the kidney transplant patient to incorrectly receive 100 milligrams of Thymoglobulin in one hour, rather than over the recommended six hours, according to the investigation.
But unlike with other patient safety lapses, the Centers for Medicare & Medicaid Services did not threaten to terminate Medicare funding for UC Irvine, notes the article.
Even though a follow-up review concluded the patient didn't die from the medication error, UC Irvine officials still submitted a correction plan this week that includes allowing only trained registered nurses to program drug pumps.
Under the correction plan, the hospital will retrain some staff members, as well as perform random audits to ensure compliance with new safety policies.
The hospital also created a pump safety committee to supervise medication delivery pumps and a patient safety steering committee to oversee the timely completion of system-wide improvement efforts.
To learn more:
- read the Los Angeles Times article
- check out the investigation findings and hospital letter