CMS cited two California hospitals with immediate jeopardy after medication errors that caused patient deaths and lifted the warnings in May following corrective plans, the Los Angeles Times reported Sept. 25.
At Adventist Health Simi Valley (Calif.), medical staff gave an 81-year-old woman two doses of Lovenox, a blood thinner, within two hours. CMS found the error "probably caused" a brain bleed, and the patient died 18 hours later. Investigators determined that the medical error was a "system wide failure" because the physician ordering the medications did not follow hospital protocol, two pharmacies filled the prescription without talking to each other, and both doses were not correct. The hospital also failed to ensure oral doses of medications had correct expiration dates, which meant patients were at risk of receiving "ineffective, incorrectly prepared, or outdated medications."
Adventist Health Simi Valley told the Times that the error was self-reported and concerns were "immediately addressed." CMS removed the immediate jeopardy warning in May after the hospital presented a corrected plan that included pharmacy alerts for certain medications.
CMS also gave Los Angeles-based Northridge Hospital Medical Center an immediate jeopardy warning after a patient had to be resuscitated after receiving the wrong medication in February.
The patient, who was recovering from anesthesia after an operation, was given a blood pressure medication instead of naloxone. The investigation also found the hospital failed to assess the patient every five minutes while under anesthesia and that nursing staff failed to regularly check the crash cart.
Northridge Hospital Medical Center, which is part of San Francisco-based Dignity Health, told the Times it reported the incident itself and "conducted a thorough review and worked closely with the medical staff, patient care staff, as well as with the Department of Public Health, to ensure that an incident like this does not happen again."
Northridge Hospital also submitted a corrective plan in May, and the immediate jeopardy warning was lifted.