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Santa Rosa Hospital Fined In Patient's Death

Posted: 2:08 pm PST March 3, 2005

The California Department of Health Services has fined Santa Rosa Memorial Hospital's nursing home facility $50,000 in connection with the death of a patient who was given the wrong medication.

The Class AA citation concerns the death of a 76-year-old woman diagnosed with colon cancer who was mistakenly given Glipizide, a medication for diabetes, by a licensed vocational nurse on May 17.

The woman died the next day of abnormally low blood sugar caused by improper medication given by medical personnel, according to the department's statement of deficiencies.

Dr. Gary Greensweig, the hospital's chief medical officer, said Thursday that the hospital does not plan to appeal the citation and $50,000 fine and has taken corrective measures to prevent further errors regarding administering the wrong medication.

Workers were being tested annually on the administration of medication and the hospital has installed an electronic dispensing system called Pyxis that needs patient and nurse identification verification before medication is made available, Greensweig said.

The hospital is not yet using a bar code system to match patients with their medication, Greensweig said.

"These events are our worst nightmare," he said.

Greensweig said studies including a 1998 report from the Institute of Medicine found that between 45,000 and 98,000 patients die annually from medical errors. An estimated 80 percent of deaths from medical errors involve improper medication, Greensweig said.

He said the staff of the nursing facility on Sotoyome Street and the hospital are deeply sorry for the patient's family.

"When these errors occur, it reflects on everyone," Greensweig said.

The report by the Department of Health Services said the nurse forgot to check the patient's armband and gave the woman diabetes medicine intended for a male patient when he was interrupted.

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