Packard Children's Hospital penalized by state

Four Bay Area hospitals, including Lucile Packard Children's Hospital at Stanford, are among 13 facilities statewide facing penalties of $25,000 for violations that were likely to cause serious injuries or death to patients, the California Department of Public Health announced Wednesday.

Lucile Packard Children's Hospital was penalized for failing to develop and implement policies and procedures specific for the use of ventilators and gases, according to the health department.

The hospital, which will not be appealing the state's decision, issued a statement in response to the penalty.

"Lucille Packard Children's Hospital at Stanford self-reported this incident to the state, and in April we met with state officials to share our belief that there was no immediate jeopardy to the patient. We are disappointed with and disagree with the state's decision."

The goal of the penalties is to ensure quality patient care for Californians, said Kathleen Billingsley, deputy director of the health department's Center for Healthcare Quality.

In addition to Packard Children's Hospital, these Bay Area hospital are among those facing penalties: Doctors Medical Center in Contra Costa County, Dominican Hospital in Santa Cruz County, and Kaiser Foundation Hospital San Jose in Santa Clara County.

The health department reported that Doctors Medical Center was penalized because it failed to develop and implement policies and procedures to protect patient safety related to the use of controlled substances.

Dominican Hospital was penalized for failing to implement policies for accurate diagnostic test review and for the maintenance of an integrated and specific patient medical record. The failure resulted in an unnecessary surgery in November.

Dominican Hospital released a statement reading, "Patient care and safety are always our highest priorities at Dominican Hospital, and we take this matter very seriously. We have conducted a thorough investigation of this matter and are working closely with our medical and diagnostic imaging staffs, and hospital leadership, as well as with the California Department of Public Health and appropriate agencies to ensure that an incident such as this never happens again."

The health department also reported that Kaiser Foundation Hospital San Jose, formerly known as Santa Teresa Medical Center, was penalized because it failed to ensure the safe delivery of patient care services and implement procedures to provide appropriate interventions and monitoring.

According to the department, the facility failed to provide stabilizing treatment to a patient with an emergency medical condition as defined by hospital policy.

On March 6, a patient entered the hospital with "flu-like symptoms" but was reclassified after a screening examination as a Priority 2, which means the patient is at high risk and needs "prompt intervention." According to the department, the emergency room was full and the patient was taken to the waiting room to wait until room became available.

The patient remained in the waiting room for just more than an hour before his wife notified a nurse that he had "passed out." A nurse assessed that the patient's heart had stopped and began cardiopulmonary resuscitation, however it failed and the patient died at the hospital, according to the department.

Terry Austen, senior vice president and area manager of Kaiser Foundation Hospital San Jose, said in a statement: "The safety of our patients is our utmost concern. When this unexpected death occurred we cooperated fully with the Department of Public Health and made immediate changes in our emergency department procedures to ensure that this type of situation will not happen again. The DPH has reviewed and approved our response and corrective actions."

Penalized facilities are required to implement a plan of correction to prevent future incidents. Facilities can appeal the penalties by requesting a hearing within 10 days of notification.

— Bay City News Service


Like this comment
Posted by Won't Visit Stanford Emergency Room Ever Again
a resident of Duveneck/St. Francis
on May 22, 2008 at 12:20 pm

Stanford is probably a good teaching hospital but it is terrible, absolutely the worst, in terms of patient care. We took our toddler to the emergency room there late one night last year with a spiking fever and chills that we thought might be convulsions. In the 104-5 degree range. It took us four hours until she was seen by an MD. FOUR HOURS we waited with her in that little room with no medication given to her at all until we made a scene and started to walk out of the facility with me loudly shouting that we were going somewhere else for medical care (we were going to drive to El Camino, maybe call an ambulance). Only then did a nurse give her some ibuprofen. and then it was another hour to see an MD. They were clearly understaffed. They told us that. We'll never go there again. Ever.

Like this comment
Posted by Mike
a resident of College Terrace
on May 22, 2008 at 3:03 pm

Never Visit.

Emergency rooms are VERY challenged these days,no matter where you go. The pathetic state of health insurance coverage is compelling financially challenged patients to use emergency rooms as a de facto doctor's office.

The best thing to do, if you're SURE there is time, and the emergency is not a "red alert" emergency, is to go to a more remote emergency room. THINK before you do this.

It's probably most always best to go someplace close, and lobby internally for immediate care if you feel you need it. Make a scene, if necessary. Emergency rooms are very chaotic and routine-dominated. IN an environment like that, sometimes you have to speak up, like you did. Doctors are not mind readers, and they, like all of us, make mistakes and get overwhelmed by stress.

btw, here's some good information on fever, in children
Web Link

Like this comment
Posted by C me around
a resident of Ventura
on May 24, 2008 at 1:41 am

I sat in a wheel chair for hours one time at Stanford, throwing up, facing the wall as I was so embarrased that other people were having to see me in that condition!
Just about everytime, myself or my children have been to Stanford's emergency room, it usually is a MINIMUM of two hours before you are escorted to a room. That's how it is. There seems to be always a room full of sick people here in Palo Alto!! You just have to wait, unfortunately as they seem to be understaffed and overworked! God bless 'em!!!
I did go in one time, again vomiting. After being checked out by the resident doctor, I had two tests ran that showed them that I had a stone partially blocking my gall bladder. I was given a nice big shot of morphine and sent home. Two days later, I returned to the emergency room and this time they kept me as I was to the point of almost passing out. They did emergency surgery on me, only to find out that now my gall bladder had gangrene.............It was the most horrific recovery time I ever had in life, worse than a horrible childbirth times 10.................Took me three months until I was able to get a nights sleep without crying in pain, even through the medication they had me on for pain.

BUT! Things happen. I am still thankful that there was a smart doctor who did such a good clean up job on my body. I was like Humpty Dumpty, they had to take my insides out and wash them down and put me back together again. THAT, I thank the Stanford doctors for. It was worth the wait........Keep the faith. I know when you or your loved one is injured that you feel you need immediate help. But they try to go case by case and sometimes the more injured have to be helped first. It just makes more trauma when you yell and carry on. A reminder to the severity of your illness should be given to the nurse upon arrival. I also found that those arriving by ambulance seem to get quicker attention and a room right away.....FYI...........

Like this comment
Posted by Patient
a resident of Another Palo Alto neighborhood
on May 26, 2008 at 6:58 am

The joke is hearing members of our City Council describe the Stanford Hospital complex as a "world class" institution, I presume they mean "third world" institution.

I recently stayed there in a shared room where a team of doctors worked all night to keep the patient next to me alive. Meanwhile, I was attempting to sleep after surgery. I was told by a Resident they had nowhere else available for either her or me. That sleepless night cost my insurance company $6,000!!! I was never so glad to get out of there.

The new hospital will have single rooms only, thank goodness.

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