Dominican Hospital Fined $50,000 for Safety Violations

Dominican Hospital in Santa Cruz was fined this week for the mistreatment of a cancer patient.

The hospital was one of 12 in the state—four in the San Francisco Bay Area—penalized for licensing requirements that are likely to cause serious injury or death to their patients, according to the California Department of Public Health, which announced the fines Thursday morning.

It was the second administrative penalty for Dominican Hospital in Santa Cruz and the first penalty for each of the other three hospitals, according to the California Department of Public Health, which announced the penalties this morning.

Each hospital was assessed a $50,000 penalty. Penalty amounts range between $25,000 and $75,000.

During a teleconference Thursday morning, Pam Dickfoss, acting deputy director of the Department of Public Health's Center for Health Care Quality, said there is a "heightened awareness" of patient safety in California, and hospitals are taking the issue seriously.

"Our goal is to improve quality care for all hospitals," Dickfoss said.

The hospitals were required to provide a plan of correction to prevent future incidents and may appeal the penalties within 10 days.

Dominican Hospital in Santa Cruz was penalized for not following policies and procedures for on-going patient monitoring and assessment of patient care.

Kaiser Foundation Hospital in San Francisco and Mills-Peninsula Medical Center in Burlingame were penalized for not following surgical policies and procedures.

Contra Costa Regional Medical Center was fined for not following policies and procedures for the safe distribution and administration of medication.

Dominican's error involved a patient who was to receive outpatient intravenous chemotherapy for testicular cancer on five consecutive days between Oct. 4-8, 2010.

The patient complained of ringing in his ears on the third and fourth day of treatment and also of feeling bloated, according to the investigation.

When symptoms worsened, the fifth day of treatment was canceled. The patient complained about having difficulty urinating on Oct. 9 and was seen in the emergency room, where a catheter was inserted to drain urine in his bladder before he was sent home.

When a physician's note indicated the patient had been given an excessive amount of the medication cisplatin, the on-call oncologist asked the patient to return to the emergency room.

The patient then received medication and fluids through a catheter in a large vein and was transferred to another hospital for a blood purification procedure, the report states.

It was determined the patient had suffered acute kidney failure from an overdose of the medication cisplatin. He received daily blood purification and dialysis, and remained in the intensive care unit for 17 days, according to the investigation.

The patient's primary oncologist stated, "I discovered that I transposed two numbers in calculating his chemotherapy doses," causing the patient to receive five times the dose of cisplatin per day over four days, according to the investigation.

The hospital's pharmacist also failed to verify the appropriate dose and frequency of chemotherapy medication, the public health department said.

The hospital revised its policy on high-risk medication, and a clinical pharmacist was deployed to review all chemotherapy orders.

—Bay City News Service