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Posted on Fri, Nov. 04, 2005
Another death in '05 attributed to hospital error
By Julie Sevrens Lyons
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
Center-Santa Clara was mistakenly given a double dose of epinephrine,
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
investigators determined that a nurse failed to check the medication
``The death of this young girl is tragic, and
we're holding the hospital
responsible,'' said Lea Brooks, a spokeswoman for the California
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
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
nurses must double-check that they have the right medication for the
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
IV drips. But after her heart and respiration rates began to rapidly
a Kaiser physician was called to the scene. He determined that a nurse
had accidentally administered two bags of epinephrine, mistaking one
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
released by the state or the hospital, ``failed to implement this
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
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
the national Institute of Medicine in 1999, estimated that such
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
that way, and a national hospital safety organization had issued a
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
wrote in their daughter's obituary, ``She was an angel who taught us
value of life.''
Josephine, who had Down's syndrome, ``loved
playing music, playing the
piano, singing, playing with her marbles and watching her favorite
videos,'' they wrote.
``Thank you God for receiving her into your
Mercury News Staff Writer David L. Beck contributed to this report.
Contact Julie Sevrens Lyons at firstname.lastname@example.org
or (408) 920-5989.
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