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The Knucklehead of the Day award

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.

*****

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.


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Comments (4)

The article doesn't say how... (Below threshold)
tyree:

The article doesn't say how crowded the emergency room was. It does say that "all prescriptions from the emergency room were considered urgent". Well, I'm not a coward so let's talk race and illegal immigration. Before I pass judgment on the health care team I would love to know how many dozens of illegal immigrants were crowded into the emergency room. I've seen the overcrowding in California emergency rooms first hand and it borders on the dangerous quite often. The politicians from both major parties don't want to admit that there just might be a downside to illegal immigration so they don't talk about it, or call us racist for just bringing up the subject. A society cannot absorb millions of illegal immigrants without serious negative side affects, and one of those is dangerously overcrowded emergency rooms. Maybe Scripps deserves the knucklehead of the day, or maybe not. We will probably never know because too much of the negative side of illegal immigration is edited from the press.

Great. The CA board has fi... (Below threshold)
epador:

Great. The CA board has fined 10 hospitals. State is threatening to withhold third party payor money. That'll really help things alot. Tyree mentions only one reason that ER's and hospitals are sorely pressed to offer health care.

I think the real knuckle-heads are the folks beating up on the hospitals (who certainly have their share of blame to shoulder) while not fixing the overall system that is threatening to collapse.

The details are lacking here, but I suspect that 3% saline was ordered. That is fairly risky and requires careful monitoring. The patient sounds like she would require admission to an ICU. The real question is why she was still in the ER and not in the ICU when all this happened? Had anyone outside the ER been consulted to evaluate the patient for admission? Anyone have a link or more information on this incident?

To add to Tyree's comments,... (Below threshold)
David in San Diego:

To add to Tyree's comments, Scripps Mercy in Chula Vista is the first hospital on this side of the San Diego/Tijuana border. Illegal aliens, who do not have health insurance and live in the area, would go there. Most of them are at a stage beyond the time when you have seen a primary physician but not yet life-threatening. Let's add to the fact that they cannot be refused medical services because they are here illegally.

The above becomes a recipe for the ER to be slammed.

Correct David, the hospital... (Below threshold)
tyree:

Correct David, the hospital might be to blame for something, but the MSM seldom reports the full story when it might reveal the truth about illegal immigration, so we just don't know.




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