header image

[Sign Up Now] to Receive Our FREE Daily SCVTV-SCVNews Digest by E-Mail

Inside
Weather


 
Calendar
Today in
S.C.V. History
March 29
1928 - Little dam victim, thought unidentified & buried in SCV, actually ID'd & buried in Chatsworth [story]
Newhall Cowboys


Henry Mayo Newhall Memorial Hospital has been fined $50,000 by the California Department of Public Health for giving a patient an overdose of an antibiotic that led to renal failure.

The fine is Henry Mayo’s first administrative penalty from the state health agency, which issued fines to 14 hospitals in California for creating situations of “immediate jeopardy” of serious injury or death for a patient.

The CDPH report says “the facility’s failure to ensure that a patient received the correct doses of medication as ordered by the physician, which resulted in the patient receiving an overdose of an antibiotic with side effects that included renal toxicity, developing acute renal failure, and undergoing hemodialysis treatment, is a deficiency that has caused, or is likely to cause, serious injury or death to the patient, and therefore, constitutes an immediate jeopardy within the meaning of Health and Safety Code Section 1280.1.”

Hospital spokeswoman Andie Bogdan issued the following statement:

“In early 2010 our pharmacy department identified a potential medication error and immediately notified appropriate hospital staff. The patient in question did not suffer any long-term damage as a result of the error, and the subsequent investigation by our staff resulted in several beneficial procedural changes shortly after the event.  Procedural and process changes included specific computerized alerts for uncommon medications and dosages. Additionally, Henry Mayo implemented house-wide a digital bedside medication verification system which uses bar coding technology to alert nursing staff if there is any discrepancy related to the right dose of the right medication for the right patient at the right time in the right route.

Henry Mayo continues to make consistent improvements in quality and safety and will continue to do so.”

In 2010, an unidentified patient was admitted to the hospital with a diagnosis of pneumonia, chest pain and abdominal pain. The physician’s assessment included “severe chronic obstructive pulmonary disease exacerbation with multi-drug resistant organisms, as well as bronchitis/pneumonia.”  The order was submitted for the patient to receive Colistin 5mg/kg IV every 8 hours in divided doses.

A handwritten direction was noted on the Medication Administration Record for Colistimethate Sodium 350 in 100 ml. sodium chloride at 100 ml. per hour intravenously every eight hours. This dosage was in proportion to the patient’s weight, which was noted as 70.3 kg (155 pounds).

Given as directed, this would have been 117 mg. every eight hours, for a total dose of 350 mg. per day. Additional investigation of the charts revealed that the licensed nurses administered 350 ml doses six times before the error was discovered.

Side effects of Colistin include tingling or numbness in the extremities and mouth, weakness of the lower limb, increased uric acid levels and creatinine levels, nephrotoxicity, dizziness, headache, slurred speech, respiratory arrest, rash and itching.  According to the report, the patient complained of numbness, dry mouth and the loss of motor ability at least three times before the physician ordered the Colistin held.

A nephrologist noted that the patient was suffering “from acute renal failure likely due to Colistin and IV contrast. The progress notes also said the pharmacy “mis-dosed” Colistin and the patient was given 5 mg every eight hours, which was not in divided doses as ordered.

Possibly the most critical information on the facility’s Medication Errors form noted that the physician prescribed an unclear order and neither the pharmacy nor the licensed nurse called the physician to clarity the prescribed unclear order.

The patient was given hemodialysis treatment and transferred to another hospital. Their final discharge diagnoses included acute renal failure.  After receiving more hemodialysis treatments at the second hospital, the patient was discharged and had to receive three more weeks of treatments before their creatinine levels returned to normal.

In response to the incident, Henry Mayo has taken a series of corrective actions, including:

– adjusting the hospital’s computer system’s doseage range alert to all, which will indicate if a dose ordered is outside of the clinically appropriate range.

– patients receiving Colistimethate will have their renal statuses checked regularly during order entry for the drug, with the physician to be contacted as necessary.

– Colistimethate was added to the Pharmacy’s Daily Clinical Reminder, the Daily Renal Monitoring report and the Daily Communication log, reminding pharmacists that review of dosage and administration is necessary.

– a multidisciplinary medication safety team was formed to analyze all medication incidents for unusual occurrences and trends.

– improved communication between clinical shifts, with special attention given to charts of patients receiving Colistimethate.

– revision of hospital policy to include “orders that state ‘give in divided doses’ must be clarified with the practitioner as to the total daily dose and the exact dose and frequency of the dose(s) to be administered,” which will force pharmacy staff to clarify orders with the issuing physicians.

– establishment of a ‘medication event’ dashboard to analyze and trend errors.

The CDPH issued a total of $850,000 in fines against a total of 14 hospitals to ensure patient safety. Legislation establishing the penalty system was authoritzed in 2007; first-offense fines such as Henry Mayo’s were $25,000 then, but were raised in 2009. First offenders are now fined $50,000, second offenses are $75,000 and third-time offenders are fined $100,000.

Comment On This Story
COMMENT POLICY: We welcome comments from individuals and businesses. All comments are moderated. Comments are subject to rejection if they are vulgar, combative, or in poor taste.
REAL NAMES ONLY: All posters must use their real individual or business name. This applies equally to Twitter account holders who use a nickname.

No Comments

    Leave a Comment


    SCV NewsBreak
    LOCAL NEWS HEADLINES
    Thursday, Mar 28, 2024
    April 16: FYI Seeks Volunteers To Pair With Local Foster Youth
    Local nonprofit Fostering Youth Independence is seeking “Allies” to support Santa Clarita youth who are aging out of the L.A. County foster care system.
    Thursday, Mar 28, 2024
    California Announces $25 Million in Awards for Youth Mental Health
    To support the mental health of California's young people, the California Department of Public Health awarded $25 million to 28 tribal and community-based organizations across the state.
    Wednesday, Mar 27, 2024
    California Launches New Youth Suicide Prevention Campaign
    The California Department of Public Health launched the “Never a Bother” campaign, a youth suicide prevention public awareness and outreach campaign for youth, young adults, and their parents, caregivers, and allies.
    Keep Up With Our Facebook

    Latest Additions to SCVNews.com
    1928 - Little dam victim, thought unidentified & buried in SCV, actually ID'd & buried in Chatsworth [story]
    Newhall Cowboys
    Los Angeles County Public Works is updating the Los Angeles County Bicycle Master Plan.
    April 16:  County Bicycle Master Plan Virtual Community Meeting
    College of the Canyons mens golf got back on track during its return to conference play on Monday, carding a five-man score of 370 to top the eight-team field at Brookside Golf Course and maintain its unblemished conference mark.
    Cougars Win Again, Keep Conference Streak
    Los Angeles County Treasurer and Tax Collector, reminds property owners that the second installment of the 2023-24 Annual Secured Property Taxes becomes  delinquent if not received by 5 p.m. Pacific Time or United States Postal Service postmarked on or before Wednesday, April 10, 2024.
    County Treasurer Reminds Property Owners of April 10 Due Date
    Local nonprofit Fostering Youth Independence is seeking “Allies” to support Santa Clarita youth who are aging out of the L.A. County foster care system.
    April 16: FYI Seeks Volunteers To Pair With Local Foster Youth
    The Los Angeles County Department of Public Health today unveiled the latest L.A. County Health Survey, which gathers vital data on health behaviors, conditions, neighborhood settings, and the needs of L.A .County residents, informing future public health policies and programs.
    Public Health Unveils the 2023 L.A. County Health Survey Findings
    Due to the projected rain forecast, Eggstravaganza will now be held indoors at the Canyon Country Community Center beginning promptly at 10 a.m. on March 30.
    March 30: Eggstravaganza Now Being Held Indoors at Canyon Country Community Center
    To support the mental health of California's young people, the California Department of Public Health awarded $25 million to 28 tribal and community-based organizations across the state.
    California Announces $25 Million in Awards for Youth Mental Health
    The College of the Canyons Athletic Department will host a dedication ceremony to unveil the Michele Jenkins Softball Team Room in honor of the longtime board member and ardent softball program supporter’s nearly 40 years of service to the district.
    April 16: COC to Host Michele Jenkins Team Room Dedication Ceremony
    PFLAG Santa Clarita has announced the establishment of the Peggy and Jeff Stabile PFLAG SCV Scholarship. The scholarship will provide financial assistance to LGBTQIA+ students pursuing higher education and committed to advocating for LGBTQIA+ rights and promoting diversity and inclusion.
    PFLAG SCV Announces Stabile PFLAG Scholarship
    1934 - Bouquet Canyon Reservoir, replacement for ill-fated St. Francis Dam & reservoir, begins to fill with water [story]
    Bouquet Reservoir
    The California Department of Public Health launched the “Never a Bother” campaign, a youth suicide prevention public awareness and outreach campaign for youth, young adults, and their parents, caregivers, and allies.
    California Launches New Youth Suicide Prevention Campaign
    The Santa Clarita Master Chorale invites the community to "Let the Sunshine In," a delightful evening of food, wine and song at the annual Cabaret & Cabernet fundraising benefit.
    April 20: Santa Clarita Master Chorale’s Cabaret, Cabernet Fundraiser
    The Los Angeles County Department of Public Health cautions residents who are planning to visit the below Los Angeles County beaches to avoid swimming, surfing, and playing in ocean waters:
    March 27 Ocean Water Warning
    As an integral ingredient necessary to help the Santa Clarita Valley to flourish, feedback from the business community is the secret sauce for achieving great things.
    SCVEDC Asks For the Business Community’s Opinion on Santa Clarita
    Raise your heart rate while raising funds for the Santa Clarita Sister Cities Dollars-for-Desks campaign to provide school desks for students in Sariaya, Santa Clarita's Sister City in the Philippines.
    April 13: Sister Cities Zumba-thon Fundraiser
    Remo, Inc. is is the world's leading manufacturer and developer of synthetic drumheads and shells. They’ve been in business for 60 years
    SCVEDC Company Spotlight: Drumming Up Big Business with Remo, Inc.
    California State Assemblywoman Pilar Schiavo (D-Chatsworth) and Assemblyman James Ramos (D-Highland) have introduced AB 3074 the "School or athletic team names: California Racial Mascots Act."
    Schiavo Introduces Bill to Prohibit ‘Derogatory’ School Mascot Names
    Los Angeles County’s Justice, Care and Opportunities Department  in collaboration with Local Initiatives Support Corporation Los Angeles is proud to announce the 2nd Annual Pitch Competition for the cohorts of JCOD's Incubation Academy.
    March 28: JCOD Incubation Academy Helps Grassroots Non-Profits For the Second Year
    Children’s Bureau is seeking foster families and now offers two virtual ways for individuals and/or couples to learn how to help children in foster care while reunifying with birth families or how to provide legal permanency by adoption.
    April 18: Children’s Bureau Hosts Virtual Orientation
    The Sunburst track was constructed in 1887 by the Southern Pacific Railroad and was a part of the main line running between San Francisco and Los Angeles.
    Enjoy Spring With a Ride On The Sunburst Track
    California State Superintendent of Public Instruction Tony Thurmond hosted a Personal Finance Summit today where he announced his support for Assembly Bill 2927 (McCarty), legislation that would require a personal finance education course for California high school graduation.
    State Superintendent Announces Support for Personal Finance Graduation Requirement
    1847 - Probable birth date of Pico Canyon oil driller Charles Alexander Mentry [story]
    C.A. Mentry
    SCVNews.com