Today’s winner is Scripps Mercy Hospital. They get the award for the following–
State health officials yesterday fined Scripps Mercy Hospital $25,000 – the maximum allowed – for the preventable death of a patient about a year ago at its Chula Vista campus.
The patient, a critically ill woman, died after hospital staff failed to administer saline solution that had been ordered more than four hours earlier.
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The patient came to the Chula Vista emergency room Feb. 28, 2008, with low blood-sodium levels but left against medical advice, the state’s report said. She returned at noon the next day in much worse condition, with high blood pressure and breathing problems.
An emergency room doctor ordered an intravenous saline solution at 6:35 p.m. – more than 2½ hours after blood test results showed that her sodium level was critically low. The same physician wrote a second order for saline solution 10 minutes later.
The hospital’s pharmacy failed to quickly process either request, in part because all prescriptions from the emergency room were considered urgent, making it difficult to prioritize them.
The patient was transferred to the intensive care unit about 9:15 p.m. A nurse determined that the woman had not received the saline solution, so the nurse faxed an order to the pharmacy.
The saline solution finally arrived at 10:45 p.m., but the nurse took a short break without administering it. The patient needed resuscitation about 11 p.m. and died 30 minutes later.
Dr. Davis Cracroft, Scripps Mercy’s senior medical director, said the hospital “relied too much on humans” for processing emergency room pharmaceutical orders.
“Anytime you throw that into the mix you can have a higher likelihood of errors,” Cracroft said.
The hospital’s nurses and pharmacy screwed up. A patient died, perhaps needlessly but we’ll never know for sure, one thing is certain. The dead woman doesn’t get a second chance. State Health Officials fined Scripps Mercy Hospital, and I make them today’s Knucklehead of the Day.
