Thu, Nov. 10, 2005
Hospitals blamed in more deaths
By David L. Beck
Kaiser Permanente officials have confirmed the deaths of two more patients caused by staff errors at its South Bay hospitals. The deaths bring to at least four the number of fatal incidents at Kaiser facilities during the past 13 months.
Three of the deaths involved either the wrong medications, or the right medications in the wrong dosage. The fourth was an elderly man who choked on food he was not supposed to have been given.
As it has before, Kaiser issued written statements saying that it “has expressed its deepest regret and sympathy to the family for their tragic loss” and accepting “full responsibility” for the errors.
Kaiser would not comment when asked whether there were any more cases that have not yet come to light.
A Mercury News search of state Department of Health Services files found that:
• A 77-year-old man was admitted to Kaiser-Santa Clara on Oct. 28, 2004, having difficulty breathing. On Nov. 1, according to the state report, his physician wrote an order to give the patient nothing by mouth because he was having difficulty eating. According to Kaiser spokesman Kevin McCormack, a nurse saw the order and put the man’s dinner in a refrigerator. But an aide, “not realizing that she wasn’t supposed to,” retrieved it and fed him at 6 p.m. By 6:30 he was having trouble breathing, and she summoned the nurse, who found him “unresponsive,” according to the state report. He died at 7:30 p.m. of what McCormack called “aspiration pneumonia.”
• Last Christmas Eve, a 64-year-old San Jose man was admitted to Kaiser-Santa Clara complaining of “vision changes” and having trouble speaking.
He was diagnosed as having suffered a stroke and put on a drug called a tissue plasminogen activator, or TPA. Approved for use in 1987, the drug is commonly given to stroke or heart attack victims to dissolve clots.
The total dosage ordered for the man was 67 milligrams, and his nurse set the IV to shut off at that point. But according to state records, another nurse, finding that there was still medication in the 100-milligram container, administered that, too. The man died in the intensive care unit on Dec. 26.
No report was made to the state until Jan. 20, and Kaiser was cited by the state for the delay.
Kaiser said it has added additional safeguards to prevent similar errors from occurring again.
The Mercury News reported last week that a 12-year-old girl was mistakenly given a double dose of a drug at Kaiser-Santa Clara in July, and that the overdose may have caused her death.
And 21-year-old Christopher Wibeto was given another patient’s chemotherapy drug at Kaiser’s Santa Teresa hospital in August. He died three days later.
In Wibeto’s case, Kaiser confirmed that it had reached a financial settlement with the family. McCormack declined to say whether there had been settlements in the other cases.
In 1999, the Institute of Medicine released a ground-breaking report that estimated that medical errors in hospitals kill between 44,000 and 98,000 Americans each year. It cited two large studies which found that “adverse events” occurred in about 3 percent of hospitalizations, although most of the incidents were not fatal.
Still, more people die each year from medical errors than from motor vehicle accidents, breast cancer or AIDS, the scientists determined.
Mercury News Staff Writer Julie Sevrens Lyons contributed to this report. Contact David L. Beck at firstname.lastname@example.org or (408) 920-5458.
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