CMS Cites Two California Hospitals Over Medication Errors, Prompting Corrective Actions
In a recent report by the Los Angeles Times, it has been revealed that the Centers for Medicare and Medicaid Services (CMS) took decisive action against two California hospitals due to grave medication errors that tragically led to patient fatalities. The CMS issued immediate jeopardy warnings to these healthcare institutions, only to lift them in May after they promptly implemented comprehensive corrective plans. The following is a detailed account of the incidents at Adventist Health Simi Valley and Northridge Hospital Medical Center, shedding light on the critical issues they faced and the subsequent steps taken to rectify them.
Adventist Health Simi Valley (Calif.) Medication Error Incident:
• At Adventist Health Simi Valley, a grave medication error occurred, causing significant harm to a patient. Medical staff mistakenly administered two doses of Lovenox, a blood-thinning medication, to an 81-year-old woman within a two-hour timeframe.
• CMS investigators found that this error was highly likely to have contributed to a brain bleed, ultimately resulting in the patient’s death 18 hours later.
• This tragic event was attributed to what CMS termed a “system-wide failure.” Several factors within the hospital’s operations contributed to this catastrophe. First, the physician responsible for ordering the medications did not adhere to hospital protocol. Additionally, two separate pharmacies filled the prescription without coordinating with each other, and both doses administered were incorrect.
• Furthermore, the hospital failed in its duty to ensure that oral doses of medications had accurate expiration dates. This oversight placed patients at risk of receiving medications that were either ineffective, incorrectly prepared or past their expiration date.
• In response to this alarming incident, Adventist Health Simi Valley took immediate corrective action. They self-reported the error and promptly addressed the concerns. As part of their remedial efforts, the hospital implemented a plan that included pharmacy alerts for specific medications to prevent such errors from recurring. Consequently, CMS lifted the immediate jeopardy warning in May, acknowledging the hospital’s commitment to improving patient safety.
Northridge Hospital Medical Center Medication Error Incident:
• Northridge Hospital Medical Center, located in Los Angeles and affiliated with San Francisco-based Dignity Health, was also cited by CMS for an immediate jeopardy situation following a medication error in February.
• In this instance, a patient who was in the process of recovering from anesthesia after a surgical operation was mistakenly administered a blood pressure medication instead of naloxone, which is used to counteract opioid overdose.
• The subsequent investigation exposed additional lapses in patient care, as the hospital failed to assess the patient’s condition every five minutes while under anesthesia. Moreover, the nursing staff did not conduct regular checks of the crash cart, which is essential for emergencies.
• Proactively addressing the issue, Northridge Hospital Medical Center self-reported the incident and conducted a comprehensive review of the situation. They collaborated closely with medical and patient care staff, as well as the Department of Public Health, to ensure that such incidents would not be repeated.
• In May, the hospital submitted a detailed corrective plan aimed at addressing the identified issues. Subsequently, CMS lifted the immediate jeopardy warning, recognizing the hospital’s dedication to enhancing patient safety and the quality of care.
In both instances, the CMS acted swiftly to address these serious medication errors, emphasizing the importance of patient safety in healthcare institutions. The subsequent corrective actions and collaboration between the hospitals and regulatory authorities serve as a reminder of the ongoing commitment to providing the highest standard of care to patients.
