UCI faulted for drug errors by Medicare

Published: Dec. 22, 2011 Updated: Dec. 23, 2011 7:05 a.m.
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UCI faulted for drug errors by Medicare

By COURTNEY PERKES / THE ORANGE COUNTY REGISTER

UC Irvine Medical Center failed to program drug pumps to stop a medication error, which "could have contributed" to the death of a kidney transplant patient, according to a federal inspection report released Thursday.
The Centers for Medicare and Medicaid Services sent investigators in August to the teaching hospital in Orange after UCI reported the medication overdose. In July, an unidentified patient was given an anti-rejection drug at too fast a rate and later died of undetermined causes.

The error was categorized as putting the patient in "immediate jeopardy," which is the most serious category of patient harm. That status was lifted the next day after UCI made changes to how the pumps were used.
The report also found that, in June, an unidentified 10-year-old boy received 30 times the normal dose of a sedative after an anesthesiologist in residency training incorrectly programmed a different pump. He survived but underwent two "rescue medications" for his heart to stabilize. That pump has since been removed from widespread use.
Hospital CEO Terry Belmont sent an e-mail to hospital staff Thursday detailing changes made, including additional training and formation of a patient safety committee.
"We are committed to providing a safe environment for patients and I believe our approach to quality performance improvement and patient safety is leading-edge," Belmont wrote. "The report from CMS reminds us that continued improvement and vigilance are essential, as is the need to maintain transparent policies and practices to sustain excellence."
In the future, UCI will face another unannounced inspection to ensure the problems have been corrected.
The 50-page document, which UCI voluntarily released after submitting a required corrective plan this week, gives the following account:
An unidentified man, 63, underwent a kidney transplant in July. During surgery, he was to receive an intravenous dose of an anti-rejection medication over six hours. Instead, a doctor in the third year of anesthesia residency programmed the infusion pump to deliver the dose in only one hour. The pump sent an alert indicating the rate was too high. The resident, however, overrode the alert. Inspectors found that the hospital failed to program the pump to stop the override, the documents say.
The hospital has since added more "hard stop" alerts that can't be overridden if a medication dose is unsafe. Such an alert is now in place for the anti-rejection drug the patient received.
After surgery, the resident removed the patient's breathing tube on his own, in violation of UCI policy for doctors in training that requires supervision. He paged his attending physician afterward and when she entered the room the patient was not breathing. She began resuscitative efforts. The patient died three days later.
In the hospital's corrective plan, UCI said the resident was disciplined for not following department policy. UCI spokesman John Murray said he could not elaborate on the punishment.
According to the federal document, when UCI reported the error the hospital "believed there may have been a connection between the medication misadministration and the patient's death." But an independent review by various transplant experts found that the improper medication dosage didn't cause the patient's death, UCI wrote in the correction plan.
Murray said the patient's family declined an autopsy.

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