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A Hospital Story

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Doctors Medical Center fined for errors
Contra Costa Times
Monday, November 24, 2008

Doctors Medical Center in San Pablo has been fined $50,000 for medical errors in which two patients died.

The state Department of Public Health announced penalties Monday against the hospital and 17 others around the state because of incidents that it said seriously jeopardized patients.

A state law that took effect last year requires hospitals to inform regulators of patient injuries that are considered preventable. After an investigation, the state can issue fines up to $25,000 per incident and mandate that hospitals carry out correction plans.

Doctors Medical Center is the only East Bay facility on the list announced Monday. It was faulted for the care of two patients: a diabetic with extremely low blood sugar levels, and a patient who developed problems after a catheter was installed.

"We always take patient care here very seriously," hospital spokeswoman Gisela Hernandez said. "We sincerely regret that these incidents occurred. However, we disagree with the state findings and we're appealing the citations."

Hernandez said the hospital's medical staff believes the errors were not linked to the patients' deaths.

One case involved a diabetic who was admitted to the hospital Aug. 17, 2007, with end-stage renal disease.

At 9 p.m. Sept. 2, a test revealed that the patient's blood sugar level was extremely low, at 22 milligrams per deciliter. The normal range is 70 to 110 milligrams.

But hospital nurses never notified the patient's physician or took other steps outlined in hospital protocols for treating such a condition, known as hypoglycemia, according to the state report.

The patient's medical records contain no evidence that repeat tests were taken to monitor blood sugar levels, state investigators concluded.

At 4:45 a.m., a nurse discovered the patient was unresponsive and cool to the touch. The nurse called an emergency team, but the resuscitation failed and the patient died at 5:13 a.m.

A nurse told investigators that after she learned of the low blood sugar level, she gave the patient orange juice with two packets of sugar, but acknowledged that she had not rechecked the blood sugar level and did not follow hospital procedures for hypoglycemia, which include using an intravenous line to bring blood sugar to an acceptable level and rechecking the blood every 15 minutes.

The nurse said she relied on her own assessment of the patient's condition and added that the patient seemed alert.

State regulators concluded that the failure to follow hospital protocols put the health and safety of diabetic patients in immediate jeopardy.

The second incident involved a patient admitted to the hospital Aug. 18, 2007, with an altered level of consciousness. On Sept. 1, a physician ordered insertion of an intravenous catheter in the patient's jugular vein to administer fluids and nutrition.

The registered nurse who installed the catheter was trained in another country and not at Doctors Medical Center. The hospital failed to ensure that the nurse was competent and had the proper training for the procedure, state regulators concluded.

An improperly installed catheter can lead to an air embolism, or blocking of an artery. The patient developed such a condition and died, regulators said.

The two cases are the second and third penalties assessed against Doctors Medical Center this year. In May, the state fined the hospital $25,000 for failing to set safe procedures for using fentanyl patches to ease chronic pain. The hospital has appealed that fine as well, Hernandez said.

"Although we disagree with the findings, we are constantly reviewing all issues thoroughly and improving oversight and reporting throughout the hospital," she said. "Appropriate action was taken to ensure patient safety."

Reach Sandy Kleffman at 925-943-8249 or