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Posted on Fri, Nov. 04, 2005 

Another death in '05 attributed to hospital error

By Julie Sevrens Lyons
Mercury News

Christopher Wibeto wasn't the only South Bay Kaiser patient to die this year after receiving the wrong medication.

In July, a 12-year-old girl hospitalized at Kaiser Permanente Medical Center-Santa Clara was mistakenly given a double dose of epinephrine, which speeds up the heart rate, state records show.

Josephine Frances Hart, a San Jose resident who loved to play with marbles, died July 26, the same day of the error. Her official cause of death is still being investigated by the county coroner's office, but state health investigators determined that a nurse failed to check the medication label.

``The death of this young girl is tragic, and we're holding the hospital responsible,'' said Lea Brooks, a spokeswoman for the California Department of Health Services.

Kaiser-Santa Clara was found to be ``deficient'' in its delivery of care, but ``there is no provision in state law for a monetary fine for hospitals,'' Brooks said. The hospital has been required to come up with a plan of action to ensure such mistakes don't happen again.

Nurses have received additional training. High-risk medications are being labeled with brightly colored stickers. And at least two registered nurses must double-check that they have the right medication for the right patient before administering it.

Josephine had been admitted to the hospital's intensive care unit for pneumonia and was supposed to have been given three medications via separate IV drips. But after her heart and respiration rates began to rapidly increase, a Kaiser physician was called to the scene. He determined that a nurse had accidentally administered two bags of epinephrine, mistaking one for an antibiotic, according to the state investigation.

``Nursing staff is required to check the medication label prior to administering,'' investigators said in their report. But the nurse, whose name has not been released by the state or the hospital, ``failed to implement this policy, which led to a negative patient outcome.''

``Kaiser Permanente has accepted full responsibility, and we deeply regret the error and have expressed our regret and sympathy to the family,'' hospital officials said in a written statement Thursday.

Medical mistakes happen in hospitals throughout the country, although most aren't fatal. One of the best gauges of medical errors, a report by the national Institute of Medicine in 1999, estimated that such mistakes kill between 44,000 and 98,000 Americans each year.

Josephine's death was one of at least two fatal errors at South Bay hospitals this summer alone.

Wibeto, who was being treated for lymphoma at Kaiser Permanente's Santa Teresa Medical Center, was given someone else's chemotherapy medication Aug. 26 and died three days later.

The 21-year-old San Jose native had received an injection of the cancer-fighting drug vincristine into his spine. The medication is usually fatal when administered that way, and a national hospital safety organization had issued a nationwide warning about this danger the month before.

``The deaths that occurred at Santa Teresa and Santa Clara are extremely rare and terribly tragic,'' hospital officials said in their statement. ``We take very seriously our responsibility to learn from these errors and improve our systems.''

Josephine's parents, who could not be reached for comment Thursday, wrote in their daughter's obituary, ``She was an angel who taught us the value of life.''

Josephine, who had Down's syndrome, ``loved playing music, playing the piano, singing, playing with her marbles and watching her favorite children's videos,'' they wrote.

``Thank you God for receiving her into your arms.''
Mercury News Staff Writer David L. Beck contributed to this report. Contact Julie Sevrens Lyons at or (408) 920-5989.

2005 and wire service sources. All Rights Reserved.