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.