State regulators faulted two hospitals in Southern California for medication errors that put patients at risk, including an elderly patient who suffered a brain bleed after receiving repeated doses of blood thinner.
At Adventist Health Simi Valley, medical staff erroneously gave an 81-year-old patient two doses of the blood thinner Lovenox within two hours, which "probably caused" a brain bleed that preceded the patient's death in March, investigators with the California Department of Public Health found.
State investigators determined that the medication error represented a "system wide failure" and may have led to the death, which occurred 18 hours after the brain bleed.
The hospital "failed to ensure that patients had been protected from medication errors," they found, declaring its faulty practices an "immediate jeopardy" situation that put patients at risk of serious harm.
Adventist Health Simi Valley said in a statement that the state agency had undertaken the review after the hospital reported the medication error to regulators, and that concerns identified by the state team were "immediately addressed."
"First and most importantly, we send our sympathies to the family," the hospital said in its statement. "Patient safety is always our No. 1 priority."
State health officials found that physician orders for medications were not properly followed at the hospital, not only for the 81-year-old who died but also for another patient receiving intravenous medication, which may have "adversely affected" their blood pressure.
In the first case, the two doses of blood thinner were verified by two pharmacies — a corporate pharmacy for the hospital system in Roseville, Calif., accessed via telehealth and a pharmacy in Simi Valley — but the two "never talked with each other after verifying each of these two doses."
Although nurses said they typically communicate with one another about medication, one appeared to be unaware that the patient had gotten an earlier dose, telling state investigators: "If I knew about the previous 60 mg dose of Lovenox then I would not have given another 40 mg dose of Lovenox ... It would have been too soon."
And neither of the doses was correct. Both of them should have been reduced based on the patient's kidney function "rather than rounding these doses up, as was done," the investigators found.
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