Medication Errors Put Patients at Risk: Disturbing Findings at Southern California Hospitals
State regulators have recently faulted two hospitals in Southern California for medication errors that have put patients at serious risk. A comprehensive investigative report has brought to light troubling findings that highlight the potential dangers faced by patients due to these errors.
One of the cases investigated involved an 81-year-old patient at Adventist Health Simi Valley who tragically suffered a brain bleed and subsequently passed away. The investigation conducted by the California Department of Public Health revealed that medical staff at the hospital had mistakenly administered two doses of the blood thinner Lovenox within a span of just two hours. These repeated doses were determined to have probably caused the brain bleed that preceded the patient’s demise in March.
Disturbingly, state investigators concluded that this medication error was indicative of a system-wide failure and potentially contributed to the patient’s death, which occurred 18 hours after the brain bleed. The hospital’s unacceptable practices were declared an immediate jeopardy situation, posing a serious threat to patients’ safety.
Adventist Health Simi Valley has responded to the investigation’s findings by stating that the state agency undertook the review after the hospital promptly reported the medication error to regulators. The hospital claims that it immediately addressed the concerns identified by the state team and emphasized that patient safety is their utmost priority.
The investigation also shed light on other medication errors at the hospital, including the improper following of physician orders for medications. Not only did this impact the 81-year-old patient who tragically passed away, but it also potentially had adverse effects on another patient receiving intravenous medication, particularly concerning their blood pressure.
In the case of the deceased patient, both doses of the blood thinner were verified by two different pharmacies, yet there was a lack of communication between them after verifying the doses. Nurses, who usually communicate with one another about medication, seemed to be unaware of the earlier dose given to the patient. The investigators were informed by one nurse that had they known about the previous dose, they would not have administered additional medication so soon.
Additionally, neither of the administered doses was correct. The investigators found that both doses should have been reduced based on the patient’s kidney function. However, this was not done, and the doses were instead rounded up, leading to potentially serious consequences.
This recent investigative report serves as a stark reminder of the need for improved medication safety protocols and practices at healthcare facilities. Preventable medication errors can have devastating consequences for patients, and it is crucial for hospitals and medical staff to ensure that proper procedures are in place to protect patients from harm.
It is hoped that the findings of this investigation will prompt hospitals and healthcare institutions to prioritize patient safety, review and strengthen their medication administration processes, and foster a culture of constant vigilance and accountability. The well-being and lives of patients depend on these critical measures being implemented effectively and consistently throughout the healthcare system.
