Kaiser Permanente appeals fine on hospital after medication error caused death
Patient Safety Monitor Alert, October 31, 2007
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Earlier this year, an infant died at Kaiser Santa Clara, the victim of a medication error, reports the San Francisco Chronicle. The boy, born with a rare metabolic disorder, was to receive a mixture of nutritional supplements and drugs. However the weight on the packaged mixture was off due to human error. As a result, the hospital, along with eight other hospitals around the state that committed similar errors, has been fined $25,000 by the California Department of Public Health (DPH).
The hospital's plan for correction was approved by the federal government. However, a California law says that the state DPH can assess a situation that is seen to put patients in "immediate jeopardy." When the DPH assessed the hospital five weeks after the incident and it found that training to prevent an error like this in the future had not occurred, it considered the situation to be placing patients in "immediate jeopardy."
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