Town Square

Stanford, PAMF unit fined in administrative errors

Original post made on Aug 31, 2012

Stanford University Hospital and Menlo Park Surgical Hospital, a unit of the Palo Alto Medical Foundation, were among 14 California hospitals cited Thursday after the California Department of Public Health found violations of licensing requirements that "caused, or (were) likely to cause, serious injury or death to patients."

Read the full story here Web Link posted Friday, August 31, 2012, 9:56 AM


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Posted by Hospitals--Enter-At-Your-Own-Risk
a resident of Another Palo Alto neighborhood
on Aug 31, 2012 at 1:47 pm

> The Stanford patient was in the Surgical Intensive Care Unit
> following treatment for a tear in his heart and placement of
> a stent.
> A tracheostomy tube was inserted after he developed
> respiratory failure.

> Without proper permission or documentation, a nurse removed the
> sutures in order to clean the area around the tube. After the
> patient stopped breathing, a doctor noted the tube had dislodged
> and the sutures were not in place.

> The patient was revived, but later died.

Errors, and other problems with health care delivery in US hospitals is a major cause of death in the US, as the following snippet of a Journal of the American Medical Association attests--

Web Link

Medical Errors - A Leading Cause of Death
The JOURNAL of the AMERICAN MEDICAL ASSOCIATION (JAMA) Vol 284, No 4, July 26th 2000 article written by Dr Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, shows that medical errors may be the third leading cause of death in the United States.

The report apparently shows there are 2,000 deaths/year from unnecessary surgery; 7000 deaths/year from medication errors in hospitals; 20,000 deaths/year from other errors in hospitals; 80,000 deaths/year from infections in hospitals; 106,000 deaths/year from non-error, adverse effects of medications - these total up to 225,000 deaths per year in the US from iatrogenic causes which ranks these deaths as the # 3 killer. Iatrogenic is a term used when a patient dies as a direct result of treatments by a physician, whether it is from misdiagnosis of the ailment or from adverse drug reactions used to treat the illness. (drug reactions are the most common cause).

Given the size of California’s population, it stands to reason that about 10% of all of these errors/deaths occur here in California.

[Portion removed by Palo Alto Online staff.]

> Stanford said the staff member was "re-educated about the
> policy which states there is a requirement to obtain a physician
> order prior to carrying out an intervention related to the removal
> of trach ties."

[Portion removed by Palo Alto Online staff.]

The article claims that the State has fined Stanford for “Administrative” errors—$50,000. But what about the dead patient’s family? Any apologies? Any compensation? Or did they bill them for tens/hundreds of thousands of dollars of medical “care” that resulted in the death of a loved one?

As usual, the Weekly’s handling of this sort of story is superficial, at best. It certainly does not seem to ask difficult questions of the State, or Stanford, regarding the number of hospital errors that occur here in California, and at Stanford.

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Posted by Neal
a resident of Community Center
on Aug 31, 2012 at 4:17 pm

Then I suggest you don't visit a doctor when you get sick or injured and refuse admittance to hospitals. Heal thy self. Doctors will thank you for staying away.

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Posted by just thinking
a resident of Another Palo Alto neighborhood
on Aug 31, 2012 at 5:14 pm

Oh please, Neal, do you really think that an ad hominem attack on a concerned fellow Palo Altan is the best way to improve hospital and medical error rates?

Physicians and other medical professionals are by and large well-meaning people who are in the profession because they are motivated to help people. Yet we have this high rate of things going wrong, things that we know how to prevent. When members of the profession engages in active quests to reduce or eliminate specific errors in specific locales, they are often successful, but these successes are not often replicated across the country.

There are industries involved in dangerous and complex duties, such as airline pilots and aircraft carriers, where the preventable accident rate is miniscule compared to medicine. These industries have been studied for what it is about them leads to such low failure rates when failure is considered not to be an option. One of the most important characteristics has to do with structure of the organizations and relationships between important players in the organization: traditional hierarchies are actually very bad for reducing errors. Medicine continues to be a traditional hierarchy for the most part, though it is evolving even in the patient doctor relationship in recent years. Nevertheless, it's nothing like the kind of organization structure you find in high-risk/low error industries.

This bears some examination, I think, for how those benefits could be applied in medicine.

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Posted by JulieB
a resident of Menlo Park
on Aug 31, 2012 at 8:15 pm

When you think about how many hours that most doctors and nurses work in hospitals, errors are bound to happen. Here is an interesting article on Managing Decision Fatigue.

Web Link

Procedure training is very important, but so is making sure they don't get decision fatigue...

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Posted by Chicken Big
a resident of College Terrace
on Sep 2, 2012 at 8:35 am

I'm confident and not at all worried about the care I receive at Stanford. My sky is still right up where it belongs, bright blue and blessed.

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Posted by Odd headline
a resident of Stanford
on Sep 2, 2012 at 12:49 pm

> removed the sutures in order to clean the area around the tube. After the patient stopped breathing, a doctor noted the tube had dislodged
and the sutures were not in place.

This is an "administrative error"?

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Posted by RN
a resident of College Terrace
on Sep 4, 2012 at 7:52 pm


If the nurse was not trained and placed in an assignment not in their skill set then it is an administrative error IMHO. These days nursing is a very specialized profession as opposed to the generalist that was the norm 20 years ago. Yet hospital administrators in a effort to save a few $$$$ here and there refuse to accept this new paradigm (Stanford is not unique in this matter BTW) and force nurse to "float' from their home units to ovoid paying overtime.

As far as not hearing about more of the details regarding the death at Stanford, I suspect we never will. HIPPA plus a settlement and non disclosure agreements with the next of kin will keep that quiet.

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Posted by susie
a resident of Barron Park
on Sep 5, 2012 at 4:54 pm


they are terrible on every clinical metric. Good research. TERRIBLE clinically.

Go to UCSF. best in the country

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Posted by susie
a resident of Barron Park
on Sep 5, 2012 at 4:55 pm

SEE what I mean. UCSF is not on the list and they are hugely bigger than Stanford or anywere.

UCSF is amazing. Go there if sick.

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Posted by Wife of M.D.
a resident of Palo Alto High School
on Sep 5, 2012 at 8:02 pm

If you have cancer or are very sick or need a second opinion, go to Mayo Clinic in Rochester, MN. People fly from all over the world for the specialized health care there. Politicians, world leaders, celebrities go there. Nothing in the nation compares to the specialized physicians at Mayo Clinic in Minnesota. You can walk in one day, have surgery the next day. No waits on MRI and CT scans because they have so many.

The medical care is terrible here in California.

With any facility, however, the right doctors are of utmost importance. There are good doctors and bad doctors; they are not all the same. Listen to your instincts, do your research.

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Posted by neighbor
a resident of Greenmeadow
on Sep 5, 2012 at 9:28 pm

Couldn't agree more with the advice to avoid Stanford Hospital at all costs. Won't even list the number of errors made when I was a patient there. Their patient care is HORRENDOUS. El Camino has the most compassionate, responsive nursing staff I've seen anywhere.

btw, one of the most common causes of "complications" in hospitals is hospital-based infections. It's a no-brainer for the most part -- screen for staph infection for all admissions and isolate when needed and EVERYONE entering a patient's room or having any patient contact MUST WASH THEIR HANDS. Studies done in hospitals that emphasized either or both of these procedures showed that infections rates decrease substantially when followed.

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Posted by Jan H.
a resident of Old Palo Alto
on Oct 4, 2012 at 11:36 pm

Jan H. is a registered user.

When I had a knee replacement in 2008, I was in Stanford Hospital for four days. During that time, I was supposed to be given a Continuous Passive Motion treatment every two hours. I got it exactly once. I was supposed to be given back the two pints of blood I had donated for the surgery immediately after the surgery. I got it three days later, when my blood pressure and blood count had gone dangerously low.

I was supposed to receive two ice packs, every two hours, around the clock. I got them twice...once because my friend went and got them, once because my physical therapist went and got them.

My vital signs were supposed to taken around the clock, but neither my hospital roommate or I saw anyone at all between 11:00pm and 7:00am. In fact, every night our morphine pump alarms went off because the pumps were empty and we were getting no pain meds. No one responded. Even when I rang repeatedly for a nurse, no one responded.

On the second day when my catheter was removed, the nurse spilled urine on me and the hospital bed. She said she would be right back to clean me up. I did not see her again until 9:00am the next day...24 hours later. I rang for he.p and got none. When my meals were brought, I asked for help, and got none. I sat in urine all day and all night and my skin blistered because of it.

I ran out of water to drink, rang for a nurse to bring more, no one came. When my meals were brought, I,asked for water. None was brought .

I asked in advance of admission for vegetarian meals....never got them. Asked twice mOre for vegetarian meals. Got bacon, a chicken leg, Mac and cheese, meatloaf. Yuck.

I asked for help with a bed bath. Never got it in four days. Mind you, a total knee replacement is extremely painful and debilitating. Even had to hop on one foot to the bathroom.

Filed a complaint. Never heard back.

Got the bill. Got charged for things I didn't get. Like the Continuous Passive Motion machine. Complained to the insurance company. Aha! The charges were removed.

Stanford deserves to fined til it hurts. What I suffered was nothing compared to what one of my friends suffered. She was caused to suffer a stroke by an erroneous treatment she received at Stanford by order of PAMF. She is extremely disabled now for life, and dry nearly died while in a comatose state for months.

I have had tests performed there by unsupervised students. My friend's daughter, who had cancer, had tests and surgeries botched by unsupervised medical students.

Stanford needs to be fined and fined and fined until they can no .onger afford to be unethical. The end
Er formed ther
Eatedly for a. Use, no one responded
Ital roommate or
Ital for four days

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Posted by pants on fire
a resident of Stanford
on Oct 5, 2012 at 1:28 pm

anyone else find the above story to incredible unbelievable?? Sounds like a series of exaggerations made to damage the reputation of a wonderful institution.
It would be akin to claiming that your neighbors think you are a loser because your company only employed 20 people!!!

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Posted by Jan H
a resident of Old Palo Alto
on Oct 5, 2012 at 7:36 pm

Hey, liar, was our medical insurance company that would not give us a group rate ecauseqeo ly employ twenty people. It is our real estate agent who thinks we are losers because we own a small company and cannot afford to buy a bigger house in PA.

Why are you so mean????

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Posted by Jan is mistaken
a resident of Midtown
on Oct 5, 2012 at 8:15 pm

Jan-in the thread ” inflation for real families” you state:

”The local restaurants treat us like losers because we buy our clothes at Target. Yes, we have nice cars, but they were bought used.

My husband has a graduate degree in economics and owns his own firm, but the banks, the medical insurance companies, and the neighbors treat us like losers because he does not take an obscene salary, takes large pay cuts before giving his employees small ones, and restores the pay cuts to employees before restoring them to himself.

He is treated like a loser because his company only employs 20 people, so he does not get good rates from insurance companies or banks. Most of the. O ey he makes goes back into the company, not our bank account”

so let's not toss around the term ”liar”!

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Posted by Jan H.
a resident of Old Palo Alto
on Oct 6, 2012 at 9:36 am

"Liar, liar" refers to the first part of the moniker "pants on fire". More importantly, why are you constantly changing your name and residence? Why are you cyber-stalking me? There is a law against cyber-stalking, and it is punishable by imprisonment.

BTW, not getting good rates on insurance is the same as not getting group rates on insurance! Banks don't give us good rates on business loans because the company is small. The neighbors further up the street do treat us like losers because we live too close to the RR tracks, a direct result of not making more money. And our real estate age t treats us like losers because she cannot find us a bigger house in our price range.
My husband could take a bigger salary, but that would not be healthy for the company finances and would put the employees' livelihoods at risk.

Why does that make me a liar?

Again, why are you so mean? And why do you repeatedly change your name and residence? To avoid detection ? To avoid prosecution for cyber-stalking?


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Posted by Jan is mistaken
a resident of Midtown
on Oct 6, 2012 at 10:57 am

You are mistaken once again, Jan. I am not changing my name and residence. You have become a prolific poster. Your comments are available for all to see. I just pointed out the fallacy in your posting, above. You claimed you did not state something, I provided the evidence that you did. I never called you a liar. I did not discuss your insurance issues, so that is irrelevant. Responding to your postings is not ” cyber-stalking”. You seem to feel that comments you post on an open forum should not be addressed by those that disagree with you..sounds to me like an attempt to limit the free exchange of opinions and not cyber stalking.

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Posted by Jan H.
a resident of Old Palo Alto
on Oct 6, 2012 at 9:34 pm

Jan H. is a registered user.

[Post removed by Palo Alto Online staff.]