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Alameda Hospital Suffers Penalities from California Department of Public Health

The California Department of Public Health (CDPH) announced yesterday that twelve California hospitals have been assessed administrative penalties for failure to comply with licensing requirements, the result of which caused, or was likely to cause, serious injury or death to patients. Alameda Hospital was one of the twelve penalized.

According to a statement from the public health agency, Alameda Hospital “failed to develop and implement written policies and procedures to ensure the safe and effective administration of medication. This is the first administrative penalty issued to this hospital. The penalty is $50,000.”

Alameda Hospital receives some $6 million per year in parcel tax funding from city of Alameda residents.

The public health department’s survey document is dated March 24th, 2010 and was signed by Alameda Hospital CEO Deborah Stebbins on October 8th, 2010.

According to the survey document, Alameda Hospital’s failure, “exposed 7 of 7 patients reviewed, who had not been on fentanyl patches prior to admission to the hospital, to preventable adverse consequences including respiratory depression (severe trouble breathing) and death. All seven patients received fentanyl patches without a pharmacist’s assessment of the appropriateness of the dose and establishing opiate tolerance prior to initiation of the patch…In addition one of the two patient’s fentanyl patch dose was double two days after starting fentanyl patches.”

Also, capitals in the original, “THE HOSPITAL’S FAILURE TO DEVELOP AND IMPLEMENT WRITTEN POLICIES AND PROCEDURES TO ENSURE SAFE MEDICATION USE HAD THE POTENTIAL TO EXPOSE PATIENTS TO IRREVERSIBLE AND POTENTIALLY LIFE THREATENING SIDE EFFECTS, INCLUDING RESPIRATORY DEPRESSION AND POSSIBLY DEATH. THIS FAILURE CAUSED, OR WAS LIKELY TO CAUSE, SERIOUS INJURY OR DEATH TO THE PATIENT, AND THEREFORE CONSTITUTED AN IMMEDIATE JEOPARDY UNDER HEALTH AND SAFETY CODE SECTION 1280.1”

According to the report, two of the seven patients were elderly with respiratory depression and were treated at the highest available size of fentanyl patches without an evaluation of such use.

8 comments to Alameda Hospital Suffers Penalities from California Department of Public Health

  • Barb

    Another bargain for those feeding at the government trough. While its ersatz watchkeepers do no more than maintain a consistent record of providing care below the standard of care in the medical community: malpractice.

  • Don

    The California Department of Public Health, Starting in 2007, has assessed a total of 198 administrative penalties against 124 California hospitals resulting in over $4.6 million in fines including Kaiser, UCSF, Sutter some of which have had repeated offenses. Here’s the actual report from CDPH.

    http://www.cdph.ca.gov/Pages/PH11-038.aspx

  • C. Gottstein

    More importantly, for Patient #3, the penalty was DEATH. You can read about it here (pg 10-11):

    http://cdph.ca.gov/certlic/facilities/Documents/HospitalAdministrativePenalties-2567Forms-LNC/2567AlamedaHospital-Alameda-Event18JB11.pdf

    I 1st heard about this @ 12:30AM, & b/c then I couldn’t sleep, I heard it again on KCBS-AM {Rebecca Corral} radio @ 2:45am, 3:45am, & 4:45am. By dawn, the story had been bumped from the airways by new violent crime. But that doesn’t make it any less important. Unfortunately for Alameda, this only validates what Denise Lai & Elliott Gorelick have been telling you. The small number of total patients seen @ Alameda Hospital in comparison #seen by other hospitals receiving administrative penalties only magnifies the harm done to these SEVEN pts by inappropriate narcotic dosing. Evidently the axiom:”any hospital on the Island is better than having to cross a bridge/Tube” needs serious re-examination

  • Liz Williams

    OMG – a pulmonologist at Alameda Hospital prescribed the highest dose (100mcg/hr) fentanyl patch for someone in respiratory distress who was not opiod tolerant? Who was it – Dr. Kevorkian?

    Or was it board member Dr. Deustch, who is a pulmonologist?

  • melo

    I use the fentanyl patch, and the packaging and pharmacy instructions say ALL over them DO NOT TAKE IF YOU ARE NOT OPIATE TOLERANT. How a doctor could miss this is beyond me. the patient might not have ever seen the packaging (probably didn’t actually) but the doctors and nurses must have, and the makers of fentanyl make it VERY clear that the patient MUST be opiate tolerant. No excuse. I am a patient, not a doctor, and I don’t see how this could happen at all.

  • A source sent this in:

    From the package insert for Duragesic (fentanyl patch):

    What are the possible side effects of DURAGESIC®?
    • DURAGESIC® can cause serious side effects, including trouble
    breathing, which can be fatal, especially if used the wrong way. See
    “What is the most important information I should know about
    DURAGESIC®?”
    Call your healthcare provider right away or get emergency medical help if
    you:
    • Have trouble breathing
    • Have extreme drowsiness with slowed breathing
    6• Have shortness of breath (little chest movement with breathing)
    • Feel faint, dizzy, confused, or have other unusual symptoms
    These can be symptoms that you have taken too much (overdose) DURAGESIC® or the dose is too high for you. These symptoms may lead to serious problems or death if not treated right away.

    There’s a link to the full text .pdf in this “black box” warning for physicians from the fda:
    http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm100223.htm

  • Barb

    Thanks Don, nice to be able to compare Alameda Hospital with the San Luis Obispo Men’s Colony Hospital, Kaiser Vallejo, and even UCSF, in receiving penalties. Some of the hospitals even receive government money, aka our tax dollars. But we have been sold a bill of goods on Alameda Hospital in order to keep some doctors with limited abilities a steady supply of patients that we subsidize. As someone pointed out recently, the hospital refuses Medicare patients. So there is discrimination in the tax subsidy that it/they will accept. Not very noble.

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